In November 1993, the 21st
Conference of Health Ministers for East, Central and
Southern Africa (ECSA) was held in Maseru, Lesotho. At this conference,
the Health Ministers adopted a resolution in
which they identified unsafe abortion
as a major cause of maternal morbidity and mortality in the region
(Kinoti, et al., 1990). In addition, the Ministers recommended specific
actions to address the problem of unsafe
abortion in member countries.
As a next step, the
Commonwealth Regional Health Community Secretariat (CRHCS)
undertook a study in 1994 to document the magnitude of abortion complications
in Commonwealth member countries and sub-Saharan Africa (SSA)
as a whole. The study involved two components:
-
A literature review
on abortion in SSA covering the years
1980–1994 and
-
Primary data collection
in three Commonwealth countries (Zambia, Uganda, Malawi) to yield
more recent findings.
The findings of that study
form the basis of this monograph.
The literature review
involved a computerised search for published literature using
various bibliographic databases and a manual search for any unpublished
documents (grey literature) available in the
Commonwealth member countries on
abortion. The search identified 99 published and 146 grey studies that
were then annotated using a standardised format.
Next, in each of the three
countries, two researchers—selected for their expertise in
women’s health issues and their research capabilities—collected
data on incomplete abortion from four
hospitals (urban and rural) using standardised
instruments. Data collection focused on the magnitude of morbidity and
mortality in the hospitals due to unsafe abortion, the cost of treating
patients with abortion complications and
provider and patient perspectives. In
Zambia, where the laws concerning abortion are less restrictive, data
also were collected on induced
abortion/menstrual regulation (MR) patients.
Collectively, the literature review findings point to a
significant public health problem as
measured by (among other statistics) a high proportion of incomplete
abortion patients among all hospital
gynaecology admissions (up to 76% in
some places). Most of the epidemiological studies, however, have been
conducted in hospital or clinic settings.
This points to the need for more community-based studies, as many maternal
deaths due to abortion complications occur
outside the formal health system.
The clinical literature
identifies haemorrhage and sepsis as the two most common complications
of abortion among women presenting at health facilities. Experiences
with the use of manual vacuum aspiration (MVA) in SSA for treating
abortion complications have been positive as measured by shorter lengths
of hospital stay and a reduced need for a repeat evacuation. Gaps in the
clinical literature exist, however, including
how the health system can expand MVA
services to lower levels of the system. In addition, very little
information exists on the cost of
treating abortion complications. One study which compared
the facility costs of MVA to sharp curettage (SC) for treating incomplete
abortion patients documented decreases of up
to 66% with the use of MVA (Johnson,
et al., 1993).
Few articles have focused on
the role of men in supporting a woman’s decision to
abort or use contraception. The paucity of literature on this topic
underscores the need for additional
research. Studies on the relationship between contraceptive
behaviour and abortion illuminate the fact that almost all patients
suffering from complications of an unsafe
abortion do not use an effective, or
any, method of contraception prior to becoming pregnant. Adolescents
are a population particularly affected
because of national policies and/or practices which
limit or prohibit distribution of contraceptives to adolescents. Reasons
cited for non-use of contraception among
females, including adolescents, include
fear of disapproval, a lack of information and/or a lack of access to
services. Research literature on postabortion
family planning (FP) services in SSA
is virtually nonexistent which most likely reflects the lack of these
services in general in the region.
This gap points to the need to initiate such services
before research studies evaluating the linkages between FP and abortion
can be conducted.
Finally, the literature on legal aspects of abortion in
SSA is abundant. Some articles
describe abortion laws and others describe administrative or bureaucratic
obstacles to obtaining legally induced
abortion in the region. Almost all of
the articles recommend law reform so that the legal code for abortion
reflects a public health rather than a
criminal orientation.
The findings of the topical
summaries can by summarised as follows:
Magnitude of Unsafe
Abortion
-
Treatment of large numbers of women with complications
of unsafe abortion is a major
problem in the health care systems of the region;
abortion complications are an important contributor to hospital-based
maternal mortality and morbidity.
-
The majority of existing epidemiological research was
carried out in hospitals where
treatment of abortion complications is offered; the
few community-based studies conducted, however, also suggest that
abortion complications are a leading cause of overall maternal mortality.
-
While women seeking care for abortion complications
may fit the profile of any woman
of reproductive age, young unmarried women with
few children are over-represented among abortion patients studied
in hospitals.
Clinical Issues
-
Haemorrhage and sepsis are the major reported causes
of abortion-related deaths.
-
Unsafe methods of induced
abortion, especially traditional methods, can
result in serious injuries and death to women.
-
Manual vacuum aspiration (MVA)
has been shown to be an effective, safe
method of uterine evacuation.
Cost Issues
-
Treatment of abortion complications represents a
significant cost to health care
systems in SSA (as measured by the use of resources such
as staff time, medications and space).
-
Hospital stays are shorter, and thus costs are lower,
for incomplete abortion patients
treated with MVA versus sharp curettage (SC).
Contraception and Abortion
-
Contraceptive use among women experiencing abortion is
relatively low.
-
Serious obstacles to contraceptive use remain,
including women’s concerns about
contraceptive side effects and lack of access to and information
about FP services.
-
Postabortion FP services/linkages are limited.
Male Perspectives
-
Little literature exists on the males role in
decisions surrounding an induced
abortion.
-
The literature that does
exist suggests that men have limited involvement in
women’s decisions to seek an abortion, except perhaps to
provide financial support.
Abortion Laws
-
Most abortion laws in SSA are restrictive, permitting
abortions only for a narrow range
of indications, for example, to save the life of the
woman.
-
Administrative requirements for legal abortion, such
as the need for consent by a
medical committee, reduce women’s access to safe,
legal services.
-
Restrictive laws foster the existence of clandestine,
poorly performed abortions.
The data collected from the three countries specifically
for this monograph confirm, for the
most part, the findings of the comprehensive literature review. The
investigators found, however, that records on abortion patients are
not well kept nor easily retrievable. Thus,
the accuracy and validity of any hospital-based
data collected from existing records may be questionable and conclusions
from such studies should be interpreted carefully. Similarly, valid
cost estimates for treating patients with
abortion complications were very difficult to
obtain in the time allocated for the study because hospital budgets and
expenditure statements are not broken down by
abortion or gynaecology services. Although
cost data were very difficult to obtain, the researchers in one country,
Malawi, estimated that the cost of treating one abortion patient with
no serious complications was higher than the
amount budgeted by the Malawi Parliament
for all health care services for each citizen for the year.
In two countries, Zambia and
Malawi, MVA was used to manage incomplete abortion,
although not at the peripheral levels. In almost all facilities surveyed
in the three countries, the providers noted
that in general, incomplete abortion patients
were not using any method of modern FP when they became pregnant. Many,
although not all, of the providers thought that FP information and services
should be
provided to abortion patients following the procedure. In most
facilities, however, neither postabortion FP counselling nor FP methods
were offered before discharge. Interestingly,
providers were almost unanimous in
their opinion that women choose to abort and providers choose to perform
the procedure despite the statutes of the
law. Given this perception, many favoured
decriminalising current abortion laws in their country.
Of the patients interviewed, the majority noted that it
took them between 1 and 2 hours to
reach the facility. This finding underscores the likelihood that hospital-
based data reflect the "tip of the
iceberg" with respect to the magnitude of
the problem in the community.
Numerous policy and programme implications were derived
from the study findings. These are
included in the monograph under each topical area and in summary
format at the end of the report. The implications summary covers the
following four areas of programmatic
importance:
-
Quality and availability
of postabortion care services
-
Management of postabortion care services
-
Accessibility of postabortion care services
-
Legal environment for postabortion care services
Study findings summarised in the initial draft of the
monograph were presented with policy
and programme implications to officials attending the 22nd Conference
of Health Ministers held in November 1994 in Blantyre, Malawi. The
implications were accepted by those attending the conference as
important issues needing to be
addressed in their respective countries, and member state
officials were encouraged to translate these implications into programme
action plans for their countries. Given
that Zambia has the most liberalised legal
provisions for abortion of the SSA Commonwealth countries, it was also
agreed by those attending that efforts need
to be made to improve the legal environment
in other countries to address the issue of unsafe abortion.1
The policy and programme
implications of the research will be summarised in a
shorter policy document which will be shared with officials at the 1995
CRHCS Conference of Health Ministers. It is
hoped that both documents will assist
policy-makers (and others in the region involved in decision-making
about how abortion patients are treated) to
promote changes needed to improve abortion
outcomes in their countries.
1Report
of the 22nd Commonwealth Regional Conference of Health Ministers
