Hailemichael Gebreselassie

The magnitude of abortion complications in Kenya

Objective  To estimate and describe the magnitude of abortion complications presenting at public hospitals in Kenya.

Caring for women with abortion complications in Ethiopia: national estimates and future implications.

CONTEXT Ethiopia liberalized its abortion law in 2005, primarily to reduce the incidence of unsafe abortion. However, little is known about the current extent and consequences of unsafe abortion. METHODS Data were collected in 2007-2008 on 1,932 women seeking postabortion care at a nationally representative sample of 344 public and private health facilities. In addition, staff respondents at 337 facilities provided information on their facilitys services and caseload. These data were used to examine patterns of abortion-related morbidity and treatment and to generate national estimates. RESULTS Almost 58,000 women sought care for complications of induced or spontaneous abortion in 2008. Three-quarters of the women received care in government facilities. Forty-one percent had moderate or severe morbidity, such as signs of infection, that were likely related to an unsafe abortion. Seven percent of all women had signs of a mechanical injury or a vaginally inserted foreign body. More than 13,000 women seeking postabortion care required a hospital stay of at least 24 hours. The case fatality rate among women seeking postabortion care in public hospitals, where the most serious complications were seen, was 628 per 100,000. CONCLUSIONS Postabortion care and safe abortion services should be further expanded and strengthened to make these services more accessible and affordable, which in turn may ease the financial burden on hospitals and allow the resources currently required for postabortion care to be used for other health needs. Ensuring that all women know that safe abortion is available and legal for many indications will further reduce morbidity from unsafe abortions.

The estimated incidence of induced abortion in Ethiopia, 2008.

CONTEXT Unsafe abortion is an important health problem in Ethiopia; however, no national quantitative study of abortion incidence exists. In 2005, the penal code was revised to broaden the indications under which induced abortion is legal. It is important to measure the incidence of legal and illegal induced abortion after the change in the law. METHODS A nationally representative survey of a sample of 347 health facilities that provide postabortion or safe abortion services and a survey of 80 professionals knowledgeable about abortion service provision were conducted in Ethiopia in 2007-2008. Indirect estimation techniques were applied to calculate the incidence of induced abortion. Abortion rates, abortion ratios and unintended pregnancy rates were calculated for the nation and for major regions. RESULTS In 2008, an estimated 382,000 induced abortions were performed in Ethiopia, and 52,600 women were treated for complications of such abortions. There were an estimated 103,000 legal procedures in health facilities nationwide--27% of all abortions. Nationally, the annual abortion rate was 23 per 1,000 women aged 15-44, and the abortion ratio was 13 per 100 live births. The abortion rate in Addis Ababa (49 per 1,000 women) was twice the national level. Overall, about 42% of pregnancies were unintended, and the unintended pregnancy rate was 101 per 1,000 women. CONCLUSIONS Unsafe abortion is still common and exacts a heavy toll on women in Ethiopia. To reduce rates of unplanned pregnancy and unsafe abortion, increased access to high-quality contraceptive care and safe abortion services is needed.

A strategic assessment of unsafe abortion in Malawi.

Abstract As part of efforts to achieve Millennium Development Goal 5 – to reduce maternal mortality by 75% and achieve universal access to reproductive health by 2015 – the Malawi Ministry of Health conducted a strategic assessment of unsafe abortion in Malawi. This paper describes the findings of the assessment, including a human rights-based review of Malawis laws, policies and international agreements relating to sexual and reproductive health and data from 485 in-depth interviews about sexual and reproductive health, maternal mortality and unsafe abortion, conducted with Malawians from all parts of the country and social strata. Consensus recommendations to address the issue of unsafe abortion were developed by a broad base of local and international stakeholders during a national dissemination meeting. Malawis restrictive abortion law, inaccessibility of safe abortion services, particularly for poor and young women, and lack of adequate family planning, youth-friendly and post-abortion care services were the most important barriers. The consensus reached was that to make abortion safe in Malawi, there were four areas for urgent action – abortion law reform; sexuality education and family planning; adolescent sexual and reproductive health services; and post-abortion care services.

The incidence of induced abortion in Malawi.

CONTEXT Abortion is legally restricted in Malawi, and no data are available on the incidence of the procedure. METHODS The Abortion Incidence Complications Methodology was used to estimate levels of induced abortion in Malawi in 2009. Data on provision of postabortion care were collected from 166 public, nongovernmental and private health facilities, and estimates of the likelihood that women who have abortions experience complications and seek care were obtained from 56 key informants. Data from these surveys and from the 2010 Malawi Demographic and Health Survey were used to calculate abortion rates and ratios, and rates of pregnancy and unintended pregnancy. RESULTS Approximately 18,700 women in Malawi were treated in health facilities for complications of induced abortion in 2009. An estimated 67,300 induced abortions were performed, equivalent to a rate of 23 abortions per 1,000 women aged 15-44 and an abortion ratio of 12 per 100 live births. The abortion rate was higher in the North (35 per 1,000) than in the Central region or the South (20-23 per 1,000). The unintended pregnancy rate in 2010 was 139 per 1,000 women aged 15-44, and an estimated 52% of all pregnancies were unintended. CONCLUSIONS Unsafe abortion is common in Malawi. Interventions are needed to help women and couples avoid unwanted pregnancy, reduce the need for unsafe abortion and decrease maternal mortality.

The severity of abortion complications in Malawi

To assess the severity of abortion complications in Malawi and to determine associated risk factors.

Meeting the need for safe abortion care in Ethiopia: Results of a national assessment in 2008

Abstract Complications of an unsafe abortion are a major contributor to maternal deaths and morbidity in Africa. When abortions are performed in safe environments, such complications are almost all preventable. This paper reports results from a nationally representative health facility study conducted in Ethiopia in 2008. The safe abortion care (SAC) model, a monitoring approach to assess the amount, distribution, use and quality of abortion services, provided a framework. Data collection included key informant interviews with 335 health care providers, prospective data on 8911 women seeking treatment for abortion complications or induced abortion and review of facility logbooks. Although the existing hospitals perform most basic abortion care functions, the number of facilities providing basic and comprehensive abortion care for the population size fell far short of the recommended levels. Almost one-half (48%) of women treated for obstetric complications in the facilities had abortion complications. The use of appropriate abortion technologies in the first trimester and the provision of post-abortion contraception overall were reasonably strong, especially in private sector facilities. Following abortion law reform in 2005 and subsequent service expansion and improvements, Ethiopia remains committed to reducing complications from an unsafe abortion. This study provides the first national snapshot to measure changes in a dynamic abortion care environment.

An assessment of abortion services in public health facilities in Mozambique: women's and providers' perspectives.

Abstract Complications of unsafe abortion contribute to high maternal mortality and morbidity in Mozambique. In 2002, the Ministry of Health conducted an assessment of abortion services in the public health sector to inform efforts to make abortion safer. This paper reports on interviews with 461 women receiving treatment for abortion-related complications in 37 public hospitals and four health centres in the ten provinces of Mozambique. One head of both uterine evacuation and contraceptive services at each facility was also interviewed, and 128 providers were interviewed on abortion training and attitudes. Women reported lengthy waiting times from arrival to treatment, far longer than heads of uterine evacuation services reported. Similarly, fewer women reported being offered pain medication than head staff members thought was usual. Less than half the women said they received follow-up care information, and only 27% of women wanting to avoid pregnancy said they had received a contraceptive method. Clinical procedures such as universal precautions to prevent infection were less than adequate, in-service training was less than comprehensive in most cases, and few facilities reviewed major complications or deaths. Use of dilatation and curettage was far more common than medical or aspiration abortion methods. Current efforts by the Ministry to improve abortion care services have focused on training of providers in all these matters and integration of contraceptive provision into post-abortion care. Résumé Les complications des avortementsàrisque contribuent au taux élevé de mortalité et morbidité maternelles au Mozambique. En 2002, le Ministère de la santé a évalué les services d’avortement dans le secteur public. Il a interrogé 461 femmes traitées pour des complications de l’avortement dans 37 hÁpitaux publics et 4 centres de santé dans les 10 provinces du Mozambique, ainsi que le chef des services d’évacuation utérine et de contraception de chaque centre ; 128 prestataires ont également été interrogés sur la formation et les attitudesàl’égard de l’avortement. Les femmes ont déclaré avoir attendu longtemps avant d’Átre traitées, plus longtemps que ne l’ont indiqué les chefs des services d’évacuation utérine. De mÁme, le nombre de femmes disant qu’on leur avait proposé des antalgiques était inférieuràla proportion jugée habituelle par les chefs de service. Moins de la moitié des femmes ont signalé avoir reçu des informations sur les soins post-avortement, et seulement 27% des femmes voulant éviter une grossesse ont déclaré avoir reçu une méthode contraceptive. Les procédures cliniques telles que les précautions d’hygiène étaient inadéquates, la formation en cours d’emploi était loin d’Átre complète, et peu de centres examinaient les raisons des complications majeures ou des décès. L’emploi de la dilatation et du curetage était beaucoup plus fréquent que les méthodes d’avortement médicamenteux ou par aspiration. Les efforts du Ministère pour améliorer les services d’avortement se sont centrés sur la formation des praticiens dans tous ces domaines et l’intégration de la contraception dans les soins après avortement. Resumen El aborto inseguro contribuye a las altas tasas de morbimortalidad materna en Mozambique. En 2002, el Ministerio de Salud evaluó los servicios de aborto del sector público para relatar los esfuerzos por hacer el aborto más seguro. En este artáculo se informa de las entrevistas con 461 mujeres atendidas por complicaciones del aborto en 37 hospitales públicos y cuatro centros de salud en diez provincias de Mozambique. En cada establecimiento se entrevistó al jefe de los servicios de evacuación endouterina y al de los servicios de anticoncepción, asá como a 128 proveedores respecto a la capacitación y las actitudes hacia el aborto. Según las mujeres, el tiempo de espera desde su llegada hasta el tratamiento fue mucho más largo que lo que informaron los jefes del servicio de evacuación endouterina. Menos mujeres informaron haber sido ofrecidas medicamentos para el dolor que lo que los jefes consideran normal. Menos de la mitad dijo que recibió información sobre los cuidados de seguimiento; sólo el 27% de las que deseaban evitar un embarazo informaron que habáan recibido un método anticonceptivo. Los procedimientos clánicos eran deficientes; por lo general, la capacitación en servicio no era exhaustiva; y en pocos establecimientos se revisaban las complicaciones mayores o las muertes. El aborto por legrado uterino instrumental era mucho más común que el aborto con medicamentos o por aspiración. Los esfuerzos actuales del ministerio por mejorar los servicios de aborto se centran en capacitar a los proveedores en estos aspectos y en integrar el suministro de anticonceptivos a la atención postaborto.

Attitudes toward abortion in Zambia

Despite Zambias relatively progressive abortion law, women continue to seek unsafe, illegal abortions. Four domains of abortion attitudes – support for legalization, immorality, rights, and access to services – were measured in 4 communities. A total of 668 people were interviewed. Associations among the 4 domains were inconsistent with expectations. The belief that abortion is immoral was widespread, but was not associated with lack of support for legalization. Instead, it was associated with belief that women need access to safe services. These findings suggest that increasing awareness about abortion law in Zambia may be important for encouraging more favorable attitudes.

Choosing early pregnancy termination methods in Urban Mozambique

Little is known about who chooses medication abortion with misoprostol and why. Women seeking early abortion in 5 public hospitals in Maputo, Mozambique were recruited in 2005 and 2006 to explore decision-making strategies, method preferences and experiences with misoprostol and vacuum aspiration for early abortion. Client screenings (n=1799), structured clinical surveys (n=837), in-depth exit interviews (n=70), and nurse focus groups (n=2) were conducted. Triangulation of qualitative and quantitative data revealed seemingly contradictory findings. Choice of method reflected womens heightened concerns about privacy, pain, quality of home support, HIV infection risk, sexuality, and safety of research participation. Urban Mozambican women are highly motivated to find early pregnancy termination techniques that they deem socially and clinically low-risk. Although 42% found vaginal misoprostol self-administration challenging and 25% delayed care for over a week to amass funds for user fees, almost all (96%) reported adequate preparation and comfort with home management. Women reported satisfaction with all methods and quality of care, even if the initial method failed or pain management or postabortion contraception were not offered. A more nuanced understanding of what women value most can yield service delivery models that are responsive and effective in reducing maternal death and disability from unsafe abortion.