Limited evidence is available on abortion complications in fragile and conflict-affected settings to identify care needs and priorities to address the challenge in these settings.
This report summarises methods, key findings, and implications of the study “Abortion-related morbidity and mortality in conflict-affected and fragile settings” conducted in Jahun, Nigeria and Bangui, Central African Republic in March 2023. In both countries, abortion-related complications are significant contributors to high maternal mortality rates.
Findings showed that women experienced more severe abortion complications compared to results of similar studies in more stable settings. Potential contributing factors include delays in accessing post-abortion care, low access to contraceptive and safe abortion care, and increased food insecurity leading to iron deficiencies and chronic anaemia.
How the research was conducted
– A cross-sectional study using prospective medical record reviews and quantitative interviews was conducted with women presenting with abortion-related complications at two hospital facilities between November 2019 and July 2021;
– Qualitative interviews with women with severe complications to understand their pathways to care;
– Facility assessments to understand their capacity to provide post-abortion care; and
– A knowledge, attitudes, behaviours, and practices survey of health professionals.
Key findings
Over 500 women were included in the study from each hospital setting. In the CAR hospital, abortion complications constituted nearly 19.9% of all pregnancy-related admissions; it was lower in the Nigerian hospital (4.2%).
– Severity of abortion-related complications was high: over 50% of complications in the CAR hospital and over 65% in the Nigerian hospital were severe.
– In the Nigerian hospital, 1 in 4 women interviewed reported having tried to induce their abortion. In the CAR hospital, the figure was nearly 1 in 2, many resulting in very severe or life-threatening complications. In both settings, most women had used unsafe methods to induce their abortions.
– There was diversity in abortion attitudes and gaps in knowledge and practice related to abortion care. A low level of knowledge about WHO-recommended medical abortion regimens was observed.
– There were a range of delays in care-seeking, with many women taking days to reach care after the onset of symptoms. Pathways to care were complex. Barriers to accessing care included difficulties in navigating the health care system and a lack of referral pathways.
Results highlight the need for greater access to high-quality contraception, safe abortion care and post-abortion care in fragile and conflict-affected settings.
A search in Google for further information from these two studies with the keywords AMoCo Study, led to a long page of documents listed under Ipas, BMC Pregnancy and Childbirth, National Institutes of Health, Epicentre/MSF, gov.uk, ScienceDirect.com, ceped.org (in French), LSHTM, IAWG, ResearchGate, Instituut voor Tropische Geneeskunde, and back again, and then crashed into a study of an oil spill in Cadiz involving the US oil company called Amoco. Take your pick!
The Ipas website reports about the study provided the following summaries of the main topics covered by the research during 2023:
Knowledge, attitudes, practices, and behaviours among providers of abortion-related care in a referral maternity hospital in Jigawa state, Nigeria
The KAPB survey consisted of a standardised anonymous questionnaire self-administered in November-December 2019 to health professionals who were involved in abortion care and literate in English. 140 of the 141 eligible staff participated. 30% of providers were midwives, 29% were nurses, 32% were assistants and 9% were physicians or medical officers. 71% were female.
About half the respondents had personal experience with abortion complications: 57% personally knew a woman who had died from complications of abortion while 45% had ever cared for a woman who died from complications of abortion. (71% had been consulted regarded an unwanted pregnancy, while 35% had been consulted by friends or family for induced abortion.
91% of respondents reported having had training on post-abortion care, but only 24% correctly identified 4 out of 5 of the abortion-related near-miss criteria (severity criteria). 85% reported training on contraception, of whom 57% and 55% were trained in the insertion of implants and IUDs respectively. 60% of respondents reported having had training on medical abortion, yet only 9% knew the correct dosage for the combined regimen of mifepristone and misoprostol, and none knew the correct misoprostol alone regimen.
Despite the restrictive legal environment for abortion in Nigeria, 79% considered post-abortion care (PAC) and 74% considered safe abortion care (SAC) to be the right of every woman in Nigeria. 64% agreed with the statement that health professionals should refer patients to another provider if they have objections to providing safe abortion. But only 51% agreed that any woman who presents with signs of an induced abortion should not be reported to the authorities, and only 38% agreed with the statement “women should always have the rights to have an induced abortion in case of unwanted pregnancy”.
34% of respondents providing PAC and 36% providing SAC reported using dilatation and curettage (D&C) even though the method is no longer recommended by WHO. About 34% of respondents had personally provided an induced abortion at least once, while 29% reported having referred at least one woman for safe abortion care in their current position.
Among those providing PAC, 92% said they would ask for husband’s consent first, and 88% would ask for parental consent if the patient was a minor. Among those providing contraception, 79% would ask for husband’s consent first, and 60% would ask for parental consent for a minor. • In response to the question, When asked if they would feel comfortable to provide SAC personally, 87% answered yes, with 97% selecting “the life of the woman is at risk” as the most acceptable indication, “when the woman’s physical health is at risk” next at 84%, “in case of confirmed fetal abnormality” 77%, but only 5% said they would provide SAC for any reason.
SOURCE: MSF-KAPB Nigeria Evidence Brief 24 July 2023
A comparable study was conducted in a referral maternity hospital in Bangui, Central African Republic
This study took place in the Maternity of Castors in Bangui, where the maternal mortality ratio is among the world’s highest (829/100,000 live births) and with abortion-related complications estimated to be responsible for 24% of maternal deaths. The 66-bed facility is one of the capital’s best-known maternities. In 2019, the facility recorded over 10,000 deliveries and assisted more than 2,600 women seeking post-abortion care. Between 2014 and 2017, abortion-related complications caused over 33% of maternal deaths in the facility (MSF).
75% of providers were midwives, 17% physicians, 2% nurses and 6% nurse/midwife assistants. Eighty-five percent were female; 92% of males were physicians and 87% of females were midwives. Personal experience with abortion complications was common: 91% of respondents knew someone personally who had died from a complication due to an unsafe abortion, while 76% had ever cared for a woman who died of complications of abortion.
Only 21% of respondents correctly identified 4 out of the 5 abortion-related near-miss criteria, 26% of the midwives but only 7% of the doctors. While 76% reported being trained on medical abortion, only 14% knew the correct dosage for the combined regimen of mifepristone and misoprostol, and none knew the correct misoprostol alone regimen.
Despite the stigma, complexities, and the restrictive legal environment for abortion in the country, providers in this hospital had positive attitudes towards abortion; 79% considered PAC and 67% considered SAC to be the right of every woman in the country.
41% of respondents providing PAC reported using D&C despite the method no longer being recommended by WHO. Despite the restrictive legal environment, 59% of providers surveyed said they would consider providing induced abortion to any woman requesting it, including minors, if they were allowed to do so. 82% said they would feel comfortable providing SAC in some circumstances: 97% for fetal anomaly, 90% for life of the woman and rape 73%, but only 12% would feel comfortable for any reason. 63% would seek consent of a parent and 39% of a husband to provide SAC.
SOURCE: MSF-KAPB-Evidence Brief REPRO-WEB
Four further reports cover aspects of dealing with severe and life-threatening abortion complications, including delays in reaching help and the extent of severity of the complications:
– https://www.ipas.org/resource/the-magnitude-and-severity-of-abortion-related-complications-in-the-castors-maternity-in-bangui-central-african-republic/ March 2022
– https://www.ipas.org/resource/reasons-for-delay-in-reaching-healthcare-with-severe-abortion-related-morbidities-qualitative-results-from-women-in-the-fragile-context-of-jigawa-state-nigeria-amoco/ December 2023
– https://www.ipas.org/resource/high-severity-of-abortion-complications-in-fragile-and-conflict%e2%80%91affected-settings-a-cross%e2%80%91sectional-study-in-two-referral-hospitals-in-sub%e2%80%91saharan-africa-amoco-study/ March 2023
– The evidence is growing: Abortion care is a necessity in humanitarian settings
There are more refugees and displaced people than ever before—more than 100 million globally, according to current estimates. While it is often believed that abortion care is not a priority need in refugee camps and other humanitarian settings, these studies add to the growing body of evidence that it is a priority need.