Trends in misoprostol use and abortion complications: a cross-sectional study from nine referral hospitals in Nigeria
by Folasade Adenike Bello, Bukola Fawole, Babawale Oluborode, Ibraheem Awowole, Theresa Irinyenikan, David Awonuga, Olabisi Loto, Adetokunbo Fabamwo, Philip Guest, Bela Ganatra
PLOS ONE, 31 December 2018
Objective: This study aimed to determine the types of complications arising from unsafe abortion in Nigeria, the trend in the use of misoprostol for induced abortion, and the relationship between the community use of misoprostol and the complications recorded.
Methods: A cross-sectional study at nine referral hospitals in South-west Nigeria. Nine years’ data were retrieved from medical records, including 699 induced abortions. Independent variable was the method of abortion; dependent variables were complications, need for treatment and mortality. Statistical significance was tested with Chi-square, Fishers’ exact and chi-square for trend tests (p<0.05).
Results: There were 699 induced abortions amongst 2,463 abortions found in records. Nearly 70% were surgical abortions, but misoprostol use significantly increased over the study period in a linear trend (Χ2 trend: 30.96, P <0.001). Patients who used misoprostol were significantly less likely to have infectious morbidity, genital tract injuries or medical complications. There was no difference in incomplete abortion in the groups. Patients were more likely to have in-patient care with surgical abortions (p<0.001), to need prolonged antibiotic regimens (p = 0.003), need further surgeries or additional specialist care (p = 0.009).
Conclusion: Misoprostol abortion has significantly increased over time, and was associated with less morbidity and need for further treatment, in this study. It appears to be the safer option.
Further details from the main text:
The independent variable was the method of abortion used. Pelvic instrumentation performed by manual vacuum aspiration or dilatation and curettage were termed as ‘surgical abortions’… Of 2,453 cases for consideration, 1,754 (71.5%) were spontaneous abortions; final analyses were therefore based on the remaining 699 (28.5%) women with induced abortions.
Table 1 shows the methods used in procuring the abortions. Most of the women (484; 69%) had surgical abortions, followed by misoprostol use. Some of the other methods used included: concoctions made up of lime, gin, aspirin and other non-steroidal anti-inflammatory drugs; oxytocics and other injections, oral or vaginal herbal preparations, blunt abdominal trauma, and mixtures of battery water (which may contain some sulphuric acid), detergents or household bleach. No one had used mifepristone.
Table 2 shows that over the study period, the proportion of women using misoprostol for induced abortions rose relative to the other methods (Χ2 trend: 30.96, P <0.001). This observed increase in misoprostol abortion, during the study period was a linear increase (Χ2GOF 10.19; p = 0.178).
Compared to patients who used misoprostol, patients who procured abortion with other methods (and specifically, surgical abortion) had disproportionately more injuries to the genital tract, were more likely to have offensive vaginal discharge, pelvic or intra-abdominal abscesses and peritonitis and were more likely to present with high-grade fever and septicemia, or develop severe medical complications. Between these two groups of patients, there was no significant difference in the occurrence of retained products of conception, complications like severe anemia or hypotension, or mortality (Table 3).
Table 4 summarizes hospital interventions following the different methods used to procure an abortion. Compared to patients who used misoprostol to procure abortion, patients who had a surgical abortion were more likely to be admitted as in-patients, have prolonged course of antibiotics, were more likely to have a laparotomy, drainage of abscesses, and were more likely to require additional specialist care.
It can be concluded that, in this study, severe complications, including infectious morbidity, are more likely to occur with surgical abortions than with misoprostol, and that misoprostol use has increased in recent years. It may be cautiously implied that misoprostol may be a safer method for abortion induction than traditional methods of abortion and surgical evacuation obtained in an illegal context. Its use for legally indicated abortion should be encouraged.