AFRICA – Understanding abortion-related complications in health facilities: results from WHO multi-country survey on abortion across 11 sub-Saharan African countries

by Zahida Qureshi, Hedieh Mehrtash, Seni Kouanda, Sally Griffin, Veronique Filippi, et al.

BMJ Global Health 2021;6(1)  (Open access)

Self-reported sources of information and help used to end pregnancy (n=602)


Introduction – Complications due to unsafe abortions are an important cause of morbidity and mortality in many sub-Saharan African countries. We aimed to characterise abortion-related complication severity, describe their management, and to report women’s experience of abortion care in Africa.

Methods – A cross-sectional study was implemented in 210 health facilities across 11 sub-Saharan African countries (Benin, Burkina Faso, Chad, Democratic Republic of Congo, Ghana, Kenya, Malawi, Mozambique, Niger, Nigeria, Uganda). Data were collected on women’s characteristics, clinical information and women’s experience of abortion care (using the audio computer-assisted self-interviewing (ACASI) system). Severity of abortion complications were organised in five hierarchical mutually exclusive categories based on indicators present at assessment. Descriptive bivariate analysis was performed for women’s characteristics, management of complications and reported experiences of abortion care by severity. Generalised linear estimation models were used to assess the association between women’s characteristics and severity of complications.

Health facilities were only eligible if they fulfilled the following characteristics: >1000 deliveries per year, a gynaecology ward and surgical capability (defined as providing the signal functions for comprehensive emergency obstetric care, which includes removal of retained products and surgical capability and, if available, abortion provision and/or post-abortion care. To ensure each facility could contribute sufficient data to the study during the 3-month data collection period, facilities reporting <10 post-abortion care patients on average over a month in the facility assessment form were excluded. In each country, data collection took place over a 3-month period between February 2017 and April 2018.

Based on WHO criteria for near miss, women who died or identified as a near-miss case were classified as a severe maternal outcome. Women presenting with severe haemorrhage, severe systemic infection or suspected uterine perforation were classified based on WHO’s criteria for potentially life-threatening conditionsModerate complications included bleeding, suspected intra-abdominal injury and infection. Mild complications included any abnormal signs from initial physical examination (vital signs, appearance, mental status, abdominal examination, gynaecological examination).

Clinical management of abortion-related complications was categorised as medically managed by uterotonics only, by uterine evacuation only or both methods. Uterotonics use was further divided into: misoprostol alone, oxytocin alone, ergometrine only and their combinations. Uterine evacuation was further examined by type of procedure: manual vacuum aspiration (MVA), dilation and curettage (D&C) and both.

Results – There were 13,657 women who had an abortion-related complication: 323 (2.4%) women were classified with severe maternal outcomes, 957 (7.0%) had potentially life-threatening complications, 7,953 (58.2%) had moderate complications and 4,424 (32.4%) women had mild complications. Severe maternal outcomes ranged from 5 per 1000 women in Niger to 48 per 1000 women in Nigeria. Potentially life-threatening complications ranged from 14 per 1000 women in Niger to 105 per 1000 women in Uganda. Moderate complications ranged from 395 per 1000 women in Malawi to 795 per 1000 women in Benin, and the mild complications ranged from 91 per 1000 women in Benin to 536 per 1000 women in Niger.

Women who were single, multiparous, presenting ≥13 weeks of gestational age and where expulsion of products of conception occurred prior to arrival to facility were more likely to experience severe complications. Overall, 66∙4% of women received uterotonics, and among those the most commonly used was oxytocin (50∙9%), followed by misoprostol (22∙7%). Uterine evacuation was performed in 77∙3% women, the most common method used was MVA (in 76∙9% women), and its use was most frequent in the moderate cases (79∙3%). Following MVA, D&C was used among 20∙1% of women. 8∙1% of the women received blood products and their use was mostly among the severe maternal outcomes (55∙4%) and potentially life-threatening complications (48∙2%). A total of 121 women underwent major surgeries. The most common were exploratory laparotomy, (76%) and hysterectomy (21∙5%). Almost 9 out of 10 women received antibiotics for prophylaxis of treatment. Among the small number of women (77, 0∙6%) who were admitted to intensive care unit, the majority were those with severe maternal outcomes.

Of the 602 women who reported induced abortion in the exit survey, 241 (39∙9%) reported that they did not receive any information about the method used to end pregnancy. For the rest, the most commonly reported sources of information were friends (33∙4%), husband /partner/boyfriend (28∙9%), followed by healthcare providers (25∙1% medical doctor, 24∙5% pharmacist, 23∙4% nurse/midwife). More than 1 in 10 women reported getting information through internet or social media, whereas only 6∙8% reported radio or TV as a source of information. In terms of receiving assistance from someone to end their pregnancy, 261 (42∙7%) of the women did not get any help. The most commonly reported assistance was from healthcare providers (23∙4% medical doctors, 21∙6% nurse/midwifes, 16∙8% pharmacist). Of note, more than one in five women reported being assisted by a friend.

Overall, 19∙1% of the women stated that they were not given explanations regarding their care and treatment. One out of three women reported that they were not able to ask questions during their examination and treatment. Overall, 18∙5% of women felt their choices and preferences were not followed during hospital stay and this differed significantly across severity categories. Women who reported not being spoken to nicely during their stay ranged between 6∙9% among women with potentially life-threatening complications and 9∙8% among women with moderate complications; 13∙2% of women reported not having received pain medications during their stay ranging from 9∙9% among women with severe complications to 14∙6% among women with moderate complications.

Discussion – Approximately half of the abortion-related complications were treated with both uterotonics and uterine evacuation. The use of both uterotonic and uterine evacuation may be a reflection of over-medicalization due to possible provider preference and practice rather than evidence-based recommendations. This is particularly important among mild complications presenting with vaginal bleeding that may have been due to medical abortion use prior to the facility. The management of abortion-related complications using safe and low-cost technologies, such as MVA, which is the recommended method of uterine evacuation, regardless of severity, is on the rise across countries in our study; however, the use of non-recommended and unsafe methods such as D&C still persists. This may be due to lack of resources (e.g. equipment and supplies) and/or training…

Furthermore, half of our cases received oxytocin as the most common method of uterotonics, rather than misoprostol, which is recommended to manage abortion-related complications. The less frequent use of misoprostol may be due to lack of availability, familiarity, training and guidelines as well as providers’ perceptions on misoprostol being a less effective and safe method of post-abortion care. The inequities in the provision of good quality care highlight the need to strengthen the adoption and implementation of evidence-based recommendations for the provision of post-abortion care.

Conclusion – There is a critical need to increase access to and quality of evidence-based safe abortion, and post-abortion care, and to improve understanding around women’s experiences of abortion care.

[Editor’s Note: This is a very important study. The text above includes much more than just the abstract of the paper. I added several paragraphs from the main text of the paper into the abstract as they give much more crucial detail from the findings.]