Nusrat Shah ( Department of Gynecology & Obstetrics, Dow Medical College & Civil Hospital, Karachi. )
Nazli Hossain ( Department of Gynecology & Obstetrics, Dow Medical College & Civil Hospital, Karachi. )
Mukhtiar Noonari ( Department of Gynecology & Obstetrics, Dow Medical College & Civil Hospital, Karachi. )
Nusrat Hassan Khan ( Department of Gynecology & Obstetrics, Dow Medical College & Civil Hospital, Karachi. )
Objective: To study the mortality and morbidity of unsafe abortion in a University Teaching Hospital.
Methods: A cross-sectional, descriptive study was conducted in Department of Obstetrics and Gynaecology, Unit III, Dow Medical College and Civil Hospital Karachi from January 2005 to December 2009. Data regarding the sociodemographic characteristics, reasons and methods of abortion, nature of provider, complications and treatment were collected for 43 women, who were admitted with complications of unsafe abortion, and an analysis was done.
Results: The frequency of unsafe abortion was 1.35% and the case fatality rate was 34.9%. Most of the women belonged to a very poor socioeconomic group (22/43; 51.2%) and were illiterate (27/43; 62.8%). Unsafe abortion followed an induced abortion in 29 women and other miscarriages in 14 women. The majority of women who had an induced abortion were married (19/29, 65.5%). A completed family was the main reason for induced abortion (14/29; 48.2%) followed by being unmarried (8/29, 27.5%) and domestic violence in 5/29 cases (17.2%). Instruments were the commonest method used for unsafe abortion (26/43;68.4%).The most frequent complication was septicaemia (34; 79%) followed by uterine perforation with or without bowel perforation (13, 30.2%) and haemorrhage (9; 20.9%). Majority of induced abortions were performed by untrained providers (22/26; 84.6%) compared to only 3/14 cases (21.4%) of other miscarriages (p=0.0001).
Conclusion: The high maternal mortality and morbidity of unsafe abortion in our study highlights the need for improving contraceptive and safe abortion services in Pakistan.
Keywords: Unsafe abortion, Maternal morbidity and maternal mortality (JPMA 61:582; 2011).
Unsafe abortion, a major public health problem worldwide, is responsible for 13% of maternal mortality and causes 70,000 maternal deaths every year, 99% of which occur in developing countries.1,2 Globally, there are 31 abortions for every 100 live births worldwide and 48% of all abortions are unsafe.3
According to World Health Organization, unsafe abortion is defined as a procedure for terminating an unwanted pregnancy, either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both.4 It has been estimated that 37% of all pregnancies are unwanted in Pakistan where every year, 890,000 induced abortions are performed (29 per 1000 women aged 15-49 years) and 197,000 women are treated in public and private teaching hospitals for complications of induced abortion (6.4/1000 women aged 15-49 years).5 A study from Pakistan has shown 1 in 7 pregnancies terminating in abortion with a post-abortion complication rate of 68.5%, fever and haemorrhage being the most common.6 The huge economic cost involved in treating these complications can exert a significant financial burden on the already fragile health care systems of developing countries and hence reduce their capacity to provide other much needed services.7
The risk of maternal mortality and morbidity associated with unsafe abortion depends upon the method of abortion and the qualification and training of service provider. Methods used for unsafe abortion including drinking toxic fluids, inserting herbal preparations, foreign bodies or inappropriate medication into the vagina generally lead to septicaemia. Dilatation and curettage performed in unhygienic settings by unskilled providers can cause uterine perforation with or without bowel perforation in addition to septicaemia.8
Hence, we conducted this study to assess the mortality and morbidity, reasons, methods, and types of providers of unsafe abortions.
Patients and Methods
This was a retrospective, cross-sectional, descriptive study conducted in Gynaecology unit III of Civil Hospital Karachi, for a period of five years, from January 2005 to December 2009. All women who presented to our department with complications of unsafe intervention for abortion and either died or suffered morbidity due to it, were included in the study. Unsafe abortion was defined as a procedure or intervention undertaken by untrained persons and/or done in unhygienic conditions for any kind of abortion, whether induced, spontaneous, missed, incomplete or therapeutic. Frequency of unsafe abortion was determined by dividing the total number of unsafe abortions by the total number of gynae admissions and multiplying by 100 (43/3185*100=1.35). Case fatality rate was expressed as the percentage of women diagnosed with unsafe abortion who died as a result of this condition during the study period eg 15/43* 100=34.9%. Morbidity was defined as a case of septic abortion where infection was limited to the uterus and responded to triple regime antibiotics followed by evacuation of infected retained products. Severe morbidity was defined as a complication where infection spread beyond the uterine cavity and required major surgery like laparotomy with or without hysterectomy. We divided cases of unsafe abortion into induced abortion where termination had been carried out for an unwanted pregnancy and other miscarriages where unsafe intervention was done for spontaneous, missed, incomplete or therapeutic abortion. Patients presenting with spontaneous, missed, incomplete or therapeutic abortion, without any prior intervention, were excluded from the study. A structured questionnaire was used to collect data. Information about patient\\\'s age, parity, marital status, sociodemographic characteristics, reason for abortion, method of abortion and type of provider, was collected by interviewing the patient or her relatives and that regarding complications of unsafe abortion and their treatment was retrieved from the patient\\\'s case files. The data was fed in the computer software program SPSS version 16 and was analyzed.
The total number of gynaecological admissions during the study period was 3,171 and 43 patients were admitted with complications of unsafe abortion giving a frequency of 1.35% (13.5 per 1000 gynaecological admissions). Fifteen of these women died (case fatality rate: 34.9%), 12 suffered morbidity (27.9%) and 16 suffered serious morbidity (37.2%). Total number of live births during this time was 11,027 and there were 154 maternal deaths (MMR: 1396.5/100,000 live births). There were 15 deaths due to unsafe abortion accounting for 9.7% of maternal deaths.
The mean age for unsafe abortion was 28 ± 6.89 years (range: 18-42) and the median parity was 3 (range 0-10). The socioeconomic characteristics of women having unsafe abortion are shown in Table-1.
There was no significant difference in socioeconomic characteristics of women having an induced abortion from those having other miscarriages.
Twenty-nine women had an induced abortion due to unwanted pregnancy whereas fourteen had other types of miscarriages. The majority of women who had an induced abortion were married (19/29, 65.5%), 8 were unmarried (27.5%), and 2 were previously married (6.8%). Three of the unmarried women had been subjected to rape. The most common reason given for induced abortion was a completed family (14/29; 48.2%). Among the women who were unmarried or previously married (10/29; 34.3%), the pregnancy was unwanted for obvious socio-cultural reasons. Physical/emotional violence was given as the reason in 5/29 cases (17.2%). One of these women had started to bleed after her husband beat her severely and then a dai was called, who performed an evacuation on her at home. The most common method used for unsafe abortion was instruments in 26/38 women (68.4%). There was no significant difference in parity, gestational age and method of abortion of induced versus other miscarriages. The only significant difference was found in age above 30 years and the type of provider (Table-2).
Table-3 shows the complications of unsafe abortion. Abdominal surgery was required in nearly half of the women admitted for unsafe abortions (20/43; 46.5%) with multiple laparotomies being required in 3(6.9%) women. Evacuations were performed in 12/43 women (27.9%). There was no significant difference in the complication rate and the rate of abdominal surgeries between the induced abortion group and that of other miscarriages. Blood transfusion was required in the majority of women (25/43; 58%), with 5 women requiring 4 or more units of blood (11.6%). Among women who died, one woman had been brought dead after getting toxic substances inserted into her vagina by a dai (7.1%), five died within an hour of arrival (35.7%), another three died the same day (20%)and the rest within 7 days. Among those who suffered morbidity, eleven women stayed in hospital for up to 7 days (39.2%), eight stayed for up to 14 days (28.5%), four up to 30 days (14.2%) and four stayed for more than 30 days (14.2%).
The overall case fatality rate of unsafe abortion in our study was very high at almost 35%. Other studies from Pakistan have reported case fatality rates of 5% and 10.5% respectively.9,10 One reason for this could be that women who died were brought late and in moribund condition. A previous study which had been conducted in our department, found unsafe abortion to be the third most common cause of maternal mortality and was responsible for 10% of maternal deaths.11 Unsafe abortion accounted for 1.35% of our gynaecological admissions which is similar to that reported from Nigeria.12
More than half the women who went for unsafe abortion were illiterate and belonged to very poor socioeconomic group. This reflects the overall situation of poverty and illiteracy in Pakistan and ours being a public hospital caters to the poorest communities of Karachi as well as the rural Sindh and Balochistan. The majority of women who went for induced abortion were married as has been reported by other studies from Pakistan.9,13 This should help clear the misconception that induced abortion is usually requested by unmarried women who engage in casual sex.
Nearly thirty-five percent of women had an induced abortion in their second trimester. In contrast, a study from Sri Lanka reported almost all induced abortions being performed in the first trimester (average gestational age of 6 weeks).14 Although, we did not evaluate the reasons for these late terminations, they may reflect the lack of empowerment of our women to make their own decisions as well as the difficulty in accessing safe abortion services.
A new and important finding of our study was that women having spontaneous abortions also went to unskilled providers and received unsafe abortion services, leading to maternal mortality and morbidity. This was unlike previous studies from Pakistan which have reported all unsafe abortions to be induced abortions only.9,10,11,13
The majority of women having induced abortions went to a dai (traditional birth attendant) for termination unlike those having other types of miscarriages who went to a doctor for post abortion care. However, there was no significant difference in the level of mortality and morbidity between the two groups. One reason for this could be misreporting of induced abortion as spontaneous abortion. Secondly, the doctors might have been inadequately trained in these procedures or may not be following the proper standards of hygiene while doing evacuations. Finally, it is possible that these doctors were not actually doctors because it is usual for dais, midwives and nurses who run their own clinics to call themselves doctors.
Why do women go to the back street clinics for induced abortion? The most important reason seems to be the fact that obstetricians and gynaecologists usually refuse to perform terminations either due to the social stigma associated with abortion or having inadequate knowledge about the abortion law. Before 1997 abortion was only allowed to save the life of the woman, but in 1997, the law was amended to allow abortion in early pregnancy, not only to save the life of the woman but also to provide necessary treatment.15 Moreover, doctors are known to refuse termination on the basis of their own personal beliefs. It has been suggested that doctors who feel ambivalence about providing abortion services, undergo a values clarification and attitude transformation exercise whence they should be able to separate their personal beliefs from their professional responsibilities of saving women\\\' lives.16 According to the FIGO Resolution 2005, doctors who refuse termination on the basis of conscientious objection are still under ethical obligation to refer women to safe services and provide the service themselves in case of an emergency.17
Instrumentation was the most frequent method used for unsafe abortion in our study (68.4%). Other studies from Pakistan have also reported instrumentation to be responsible for 40% and 63.8% cases of unsafe abortion respectively.10,18 Morbidity and mortality can be avoided by training the primary care providers in medical methods of termination using prostaglandins (misoprostol) and in the technique of manual vacuum aspiration (MVA) which has been proven to be more safe compared to sharp curettage for termination of early pregnancy.19-21
Almost half the women who went for induced abortions did not want any more children. This means they were using abortion as a method of family planning. A study from Aga Khan University Hospital, Pakistan has indicated that women will choose to have induced abortion to attain their goal of desired family size rather than use modern methods of family planning, even when they are aware of the risk of morbidity and mortality.6 This reflects poorly upon our family planning programme which has failed to create the awareness among the public that unwanted pregnancies should be prevented rather than terminated. Contraception and safe abortion services are both life saving interventions and are an integral part of women\\\'s sexual and reproductive rights.22 The second important reason for induced abortion was being unmarried, in eight out of twenty-nine women. Sexuality is one of the most sensitive issues associated with adolescence in our society. Access to reproductive health information and services, which could help adolescents grow into mature and responsible adults is usually completely denied to them, thus making them vulnerable to substance abuse, sexual exploitation and violence, sexually transmitted infections including HIV/AIDS and unwanted pregnancy.23 It is a sexual and reproductive right of adolescents that they should be provided with information and services on promoting safe sexual behaviours including abstinence, delayed age of onset of sexual intercourse, preventing unwanted and early pregnancies, and preventing STIs including HIV/AIDS.23
Three unmarried women were victims of rape, two of whom were 18 years old. In addition, five women had induced abortion due to physical/emotional types of domestic violence. Violence against women is endemic in our society. Rapes, gang rapes and marital rape can all result in unwanted pregnancy which can have catastrophic consequences for the woman. A qualitative study from Karachi, Pakistan, has shown sexual coercion and non consensual sex to be common and women finding it difficult to negotiate safe sex, which results in unwanted pregnancies, some of which may lead to unsafe abortions.24 According to a WHO policy framework, the decision makers in the health sector should design a health policy and service measures that can provide comprehensive, sensitive and quality care to victims of sexual violence. It recommends the formation of rape crisis centers, where all services of police departments, health services, prosecutors, social welfare agencies, and non-governmental service providers, can be coordinated under one roof.25
There may be several methodological flaws in our study. First, since abortion is a taboo subject, there could have been misreporting of induced abortion as spontaneous or incomplete abortion. Secondly, reason for unwanted pregnancy was asked as an open-ended question rather than enquiring about each individual reason. For example patients were not asked about use of contraception and contraceptive failure. Finally, gestational age could not be calculated accurately for all patients as in some cases, the date of the last menstrual period was not known and no first trimester dating scan was available to confirm the dates.
Our results indicate that unsafe abortion is a major cause of maternal mortality and morbidity, mostly because the service is being provided by untrained health care providers in unhygienic conditions. Since maternal mortality is a violation of the women\\\'s basic human right - the right to life, there is an urgent need to prevent these unnecessary deaths by improving the quality of family planning programme and providing safe abortion services.
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