Quantifying the global burden of morbidity due to unsafe abortion: Magnitude in hospital-based studies and methodological issues

Infections caused by Clostridium perfringens and Paeniclostridium sordellii after unsafe abortion

After the legalisation of abortion in the USA in 1973, the risk of infectious morbidity and mortality from this procedure notably decreased. With increasingly restrictive legislation targeting access to safe abortion services, reviewing infectious complications of unsafe pregnancy termination is crucial, particularly the diagnosis and management of life-threatening clostridial (and related anaerobic bacterial) infections that can complicate unsafe abortion. This Review deals with two especially devastating infections that are well-documented causes of septic abortion: the anaerobic, spore-forming pathogens Clostridium perfringens and Paeniclostridium sordellii. We seek to familiarise the reader with these bacteria, the clinical syndromes they can cause (with a focus on toxic shock syndrome), and provide a review of diagnosis and treatment options.

Incidence of and Experiences with Abortion Attempts in Soweto, South Africa: Respondent-Driven Sampling Study

BACKGROUND

Estimation of abortion incidence, particularly in settings where most abortions occur outside of health facility settings, is critical for understanding information gaps and service delivery needs in different settings. However, the existing methods for measuring out-of-facility abortion incidence are plagued with methodological challenges. Respondent-driven sampling (RDS) may offer a methodological improvement in the estimation of abortion incidence.

OBJECTIVE

In this study, we tested the feasibility of using RDS to recruit participants into a study about abortion and estimated the proportion of people who ever attempted abortion as well as 1-year and 5-year incidence of abortion (both in-facility and out-of-facility settings) among women of reproductive age in Soweto, South Africa.

METHODS

Participants were eligible if they identified as a woman; were aged between 15 and 49 years; spoke English, Tswana, isiZulu, Sotho, or Xhosa; and lived in Soweto. Working with community partners, we identified 11 seeds who were provided with coupons to refer eligible peers to the study. Upon arrival at the study site, the recruits completed an interviewer-administered questionnaire that solicited information about demographic characteristics, social network composition, health behaviors, sexual history, pregnancy history, and experience with abortion; recruits also received 3 recruitment coupons. Recruitment was tracked using coupon numbering. We used the RDS-II estimator to estimate the population proportions of demographic characteristics and our primary outcome, the proportion of people who ever attempted abortion.

RESULTS

Between April 4, 2018, and December 17, 2018, 849 eligible participants were recruited into the study. The estimated proportion of people who ever attempted abortion was 12.1% (95% CI 9.7%-14.4%). A total of 7.1% (95% CI 5.4%-8.9%) reported a facility-based abortion, and 4.4% (95% CI 3.0%-5.8%) reported an out-of-facility abortion.

CONCLUSIONS

The estimated proportion of people who ever attempted abortion of 12% (102/849) in our study likely represents a substantial underestimation of the actual proportion of abortion attempts among this study population-representing a failure of the RDS method to generate more reliable estimates of abortion incidence in our study. We caution against the use of RDS to measure the incidence of abortion because of persistent concerns with underreporting but consider potential alternative applications of RDS with respect to the study of abortion.

Post-abortion Complications: A Narrative Review for Emergency Clinicians

An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.

Publicly Funded Abortion and Marginalised People’s Experiences in Catalunya

Abortion law reforms enacted in Spain in 2010 and extended to Catalunya expanded access to abortion. Simultaneously, the autonomous region was affected by economic crisis and austerity, affecting access to care for migrant and marginalised populations. Mixed-method ethnographic data were collected in relation to low-income and immigrant women seeking abortion in two phases: (1) 2012–2013 and (2) early 2016. Data sources included surveys, interviews and participant observation. Data analysis combined descriptive statistics, modified Grounded Theory, thematic analysis and constant comparative methods. Despite public funding of care in a system ostensibly available to all, marginalised people seeking abortion reported reduced access and more barriers to access. Participant experiences with legal, publicly funded abortion revealed bureaucratic difficulties and delays as well as inconsistent and inadequate information. Data on marginalised people’s experiences demonstrate that even where abortion is legal and ostensibly available, politico-economic contexts and trends affect their access to abortion and public health care.

Advocating safe abortion: outcomes of a multi-country needs assessment on the potential role of national societies of obstetrics and gynecology

In 2019 the International Federation of Gynecology and Obstetrics (FIGO) embarked on an initiative that aims to strengthen the capacity of 10 national societies of obstetrics and gynecology (ObGyn) in advocacy for safe abortion. In 2018 needs assessments that entailed a desk study, interviews, and stakeholder workshops were conducted in Benin, Cameroon, Côte d'Ivoire, Kenya, Mali, Mozambique, Panama, Peru, Uganda, and Zambia. The general aim of the needs assessments was to gain a deeper understanding of the contextual situation and identify the needs of ObGyn societies in relation to safe abortion advocacy. This paper provides a cross‐country analysis of the outcomes of the needs assessments and reflects on the capabilities, barriers, and opportunities to strengthen this role of ObGyn societies. Common barriers, such as unavailability of services, lack of technical guidance, unawareness and ambiguity about the legal framework, provider attitudes, and abortion stigma, pose challenges for ObGyn societies to work constructively on safe abortion advocacy. However, ObGyn societies have a strong position due to their strategic networks and technical credibility and can be a facilitator in healthcare providers’ advocacy role. Five strategies were developed to strengthen the capacity of ObGyn societies in safe abortion advocacy.

ObGyn societies have the potential to advance women's health and rights to safe abortion care by strengthening their advocacy role through a multi‐strategy approach.

Assessing the effectiveness of empiric antimicrobial regimens in cases of septic/infected abortions

INTRODUCTION

Infected abortion is a life-threatening condition that requires immediate surgical and medical interventions. We aimed to assess the common pathogens associated with infected abortion and to test the microbial coverage of various empiric antimicrobial regimens based on the bacteriological susceptibility results in women with infected abortions.

METHODS

A retrospective study in a single university-affiliated tertiary hospital. Electronic records were searched for clinical course, microbial characteristics, and antibiotic susceptibility of all patients diagnosed with an infected abortion. The effectiveness of five antibiotic regimens was analyzed according to bacteriological susceptibility results.

RESULTS

Overall, 84 patients were included in the study. The mean age of patients was 32.3(SD ± 5.8) years, and the median gestational age was 15 (IQR 8-19) weeks. Risk factors for infection were identified in 23 patients (27.3%), and included lack of medical insurance (n = 12), recent amniocentesis/chorionic villus sampling or fetal reduction due to multifetal pregnancies (n = 10). The most common pathogens isolated were Enterobacteriaceae (35%), Streptococci (31%), Staphylococci (9%) and Enterococci (9%). The combination of intravenous ampicillin, gentamicin and metronidazole showed significant superiority over all the other tested regimens according to the susceptibility test results. Piperacillin-tazobactam as an empiric single-agent drug of choice and provided a superior microbial coverage, with a coverage rate of 93.3%.

CONCLUSIONS

A combination of ampicillin, gentamicin, and metronidazole had a better spectrum of coverage as a first-line empiric choice for patients with infected abortion.

Unsafe abortion and abortion-related death among 1.8 million women in India

Introduction

Unsafe abortion is a preventable cause of maternal mortality. While studies report high number of abortions in India, the population-level rates of unsafe abortion and their risk factors are not well understood. Our objective was to analyse the rates of and risk factors for unsafe abortion and abortion-related maternal death in India.

Methods

We conducted a secondary analysis of data from 1 876 462 pregnant women aged 15–58 years from nine states in the Indian Annual Health Survey (2010–2013). We calculated the rate of unsafe abortion and abortion-related mortality with 95% CI. Multivariable logistic regression models examined the associations of sociodemographic characteristics, health seeking behaviours and family planning with unsafe abortion and abortion-related mortality.

Results

There were 89 447 abortions among 1 876 462 pregnant women in 2007–2011 (4.8%; 95% CI 4.8 to 4.9). Of these, 58 266 were classified as unsafe (67.1%; 95% CI 66.7 to 67.5). There were 253 abortion-related maternal deaths (0.3%; 95% CI 0.2 to 0.3). Factors associated with unsafe abortion: maternal age 20–24 years (adjusted OR (aOR): 1.13; 95% CI 1.09 to 1.18), illiteracy (aOR: 1.48; 95% CI 1.39 to 1.59), rural residence (aOR: 1.26; 95% CI 1.21 to 1.32), Muslim religion (aOR: 1.16; 95% CI 1.12 to 1.22), Schedule caste social group (aOR: 1.08; 95% CI 1.04 to 1.12), poorest asset quintile (aOR: 1.45; 95% CI 1.38 to 1.53), antenatal care (aOR: 0.69; 95% CI 0.67 to 0.72), no surviving children (aOR: 1.30; 95% CI 1.16 to 1.46), all surviving children being female (aOR: 1.12; 95% CI 1.07 to 1.17), use of family planning methods (aOR: 0.69; 95% CI 0.66 to 0.71). Factors associated with abortion-related deaths: maternal age 15–19 (aOR: 7.79; 95% CI 2.73 to 22.23), rural residence (aOR: 3.28; 95% CI 1.76 to 6.11), Schedule tribe social group (aOR: 4.06; 95% CI 1.39 to 11.87).

Conclusion

Despite abortion being legal, the high estimated prevalence of unsafe abortion demonstrates a major public health problem in India. Socioeconomic vulnerability and inadequate access to healthcare services combine to leave large numbers of women at risk of unsafe abortion and abortion-related death.

The magnitude and severity of abortion-related morbidity in settings with limited access to abortion services: a systematic review and meta-regression

Introduction

Defining and accurately measuring abortion-related morbidity is important for understanding the spectrum of risk associated with unsafe abortion and for assessing the impact of changes in abortion-related policy and practices. This systematic review aims to estimate the magnitude and severity of complications associated with abortion in areas where access to abortion is limited, with a particular focus on potentially life-threatening complications.

Methods

A previous systematic review covering the literature up to 2010 was updated with studies identified through a systematic search of Medline, Embase, Popline and two WHO regional databases until July 2016. Studies from settings where access to abortion is limited were included if they quantified the percentage of abortion-related hospital admissions that had any of the following complications: mortality, a near-miss event, haemorrhage, sepsis, injury and anaemia. We calculated summary measures of the percentage of abortion-related hospital admissions with each complication by conducting meta-analysis and explored whether these have changed over time.

Results

Based on data collected between 1988 and 2014 from 70 studies from 28 countries, we estimate that at least 9% of abortion-related hospital admissions have a near-miss event and approximately 1.5% ends in a death. Haemorrhage was the most common complication reported; the pooled percentage of abortion-related hospital admissions with severe haemorrhage was 23%, with around 9% having near-miss haemorrhage reported. There was strong evidence for between-study heterogeneity across most outcomes.

Conclusions

In spite of the challenges on how near miss morbidity has been defined and measured in the included studies, our results suggest that a substantial percentage of abortion-related hospital admissions have potentially life-threatening complications. Estimates that are more reliable will only be obtained with increased use of standard definitions such as the WHO near-miss criteria and/or better reporting of clinical criteria applied in studies.

Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil

Around 18 million unsafe abortions occur in low and middle-income countries and are associated with numerous adverse consequences to women's health. The time taken by women with complications to reach facilities where they can receive appropriate post-abortion care can influence the risk of death and the extent of further complications. All women aged 18+ admitted for abortion complications to public-sector hospitals in three capital cities in the Northeastern Brazil between August-December 2010 were interviewed; medical records were extracted (N = 2,804). Nearly all women (94%) went straight to a health facility, mainly to a hospital (76.6%); the rest had various care-seeking paths, with a quarter visiting 3+ hospitals. Women waited 10 hours on average before deciding to seek care. 29% reported difficulties in starting to seek care, including facing challenges in organizing childcare, a companion or transport (17%) and fear/stigma (11%); a few did not initially recognize they needed care (0.4%). The median time taken to arrive at the ultimate facility was 36 hours. Over a quarter of women reported experiencing difficulties being admitted to a hospital, including long waits (15%), only being attended after pregnant women (8.9%) and waiting for a bed (7.4%). Almost all women (90%) arrived in good condition, but those with longer delays were more likely to have (mild or severe) complications. In Brazil, where access to induced abortion is restricted, women face numerous difficulties receiving post-abortion care, which contribute to delay and influence the severity of post-abortion complications.

Maus-tratos e discriminação na assistência ao aborto provocado: a percepção das mulheres em Teresina, Piauí, Brasil

Resumo O tratamento das complicações do aborto provocado pode ser dificultado por atitudes de discriminação praticadas por profissionais de saúde nos hospitais e serviços de aborto. Este artigo recuperou histórias de violência institucional entre mulheres que provocaram o aborto em condições ilegais e inseguras. Foram entrevistadas 78 mulheres internadas em um hospital público de referência em Teresina por complicações do aborto provocado. Utilizou-se roteiro semiestruturado com perguntas sobre práticas e itinerários de aborto e violência institucional durante a internação. Práticas discriminatórias e de maus-tratos durante a assistência foram relatadas por 26 mulheres, principalmente entre aquelas que confessaram a indução do aborto. Julgamento moral, ameaças de denúncia à polícia, negligência no controle da dor, longa espera pela curetagem uterina e internação conjunta com puérperas foram os principais tipos de violência institucional narrados. As práticas de violência institucional na assistência ao aborto provocado violam o dever de acolhimento do serviço de saúde e impedem que as mulheres tenham suas necessidades de saúde atendidas.

WHO Multi-Country Survey on Abortion-related Morbidity and Mortality in Health Facilities: study protocol

Introduction

According to the WHO, abortion accounts for about 8% (4.7–13.2) of maternal mortality worldwide. In 2010, the WHO Multi-Country Survey (MCS) on Maternal and Newborn Health collected data on over 300 000 women who were admitted in health facilities to receive pregnancy-related care. Abortion data were partially captured by centring on severe maternal outcomes (ie, near-miss or maternal deaths). Building on the experiences of the prior MCS as well as current WHO reproductive health projects, we are undertaking a multi-country survey to better capture the burden and severity of abortion-related complications and management among women presenting to the health facilities.

Methods and analysis

This is a large cross-sectional study with prospective data collection. It will be implemented in health facilities in 30 countries across the WHO regions of Africa, Americas, Eastern Mediterranean, Europe, South East Asia and Western Pacific. Countries and facilities will be identified through a multistage sampling methodology. Data collection will be at both the facility and individual levels, involving review of medical records and exit surveys with eligible women using audio computer-assisted self-interview. All women presenting to the health facilities with signs and symptoms of abortion complications will comprise the study population. Online data entry and management will be performed on a web-based data management system. Analysis will include prevalence of abortion-related complications and descriptive frequencies of procedural/non-procedural management and experience of care.

Ethics and dissemination

Ethical issues of the consent process are addressed. Dissemination plans will involve the participating facilities and communities to further strengthen abortion-related research capacity within the MCS on Abortion (MCS-A) countries. Furthermore, dissemination of results will be an iterative process at both the facility and national level to potentially propagate positive changes to abortion-related policies and practices.

Antibiotics for treating septic abortion

BACKGROUND

A septic abortion refers to any abortion (spontaneous or induced) complicated by upper genital tract infection including endometritis or parametritis. The mainstay of treatment of septic abortion is antibiotic therapy alone or in combination with evacuation of retained products of conception. Regimens including broad-spectrum antibiotics are routinely recommended for treatment. However, there is no consensus on the most effective antibiotics alone or in combination to treat septic abortion. This review aimed to bridge this gap in knowledge to inform policy and practice.

OBJECTIVES

To review the effectiveness of various individual antibiotics or antibiotic regimens in the treatment of septic abortion.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and POPLINE using the following keywords: 'Abortion', 'septic abortion', 'Antibiotics', 'Infected abortion', 'postabortion infection'. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov for ongoing trials on 19 April, 2016.

SELECTION CRITERIA

We considered for inclusion randomised controlled trials (RCTs) and non-RCTs that compared antibiotic(s) to another antibiotic(s), irrespective of route of administration, dosage, and duration as well as studies comparing antibiotics alone with antibiotics in combination with other interventions such as dilation and curettage (D&C).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from included trials. We resolved disagreements through consultation with a third author. One review author entered extracted data into Review Manager 5.3, and a second review author cross-checked the entry for accuracy.

MAIN RESULTS

We included 3 small RCTs involving 233 women that were conducted over 3 decades ago.Clindamycin did not differ significantly from penicillin plus chloramphenicol in reducing fever in all women (mean difference (MD) -12.30, 95% confidence interval (CI) -25.12 to 0.52; women = 77; studies = 1). The evidence for this was of moderate quality. "Response to treatment was evaluated by the patient's 'fever index' expressed in degree-hour and defined as the total quantity of fever under the daily temperature curve with 99°F (37.2°C) as the baseline".There was no difference in duration of hospitalisation between clindamycin and penicillin plus chloramphenicol. The mean duration of hospital stay for women in each group was 5 days (MD 0.00, 95% CI -0.54 to 0.54; women = 77; studies = 1).One study evaluated the effect of penicillin plus chloramphenicol versus cephalothin plus kanamycin before and after D&C. Response to therapy was evaluated by "the time from start of antibiotics until fever lysis and time from D&C until patients become afebrile". Low-quality evidence suggested that the effect of penicillin plus chloramphenicol on fever did not differ from that of cephalothin plus kanamycin (MD -2.30, 95% CI -17.31 to 12.71; women = 56; studies = 1). There was no significant difference between penicillin plus chloramphenicol versus cephalothin plus kanamycin when D&C was performed during antibiotic therapy (MD -1.00, 95% CI -13.84 to 11.84; women = 56; studies = 1). The quality of evidence was low.A study with unclear risk of bias showed that the time for fever resolution (MD -5.03, 95% CI -5.77 to -4.29; women = 100; studies = 1) as well as time for resolution of leukocytosis (MD -4.88, 95% CI -5.98 to -3.78; women = 100; studies = 1) was significantly lower with tetracycline plus enzymes compared with intravenous penicillin G.Treatment failure and adverse events occurred infrequently, and the difference between groups was not statistically significant.

AUTHORS' CONCLUSIONS

We found no strong evidence that intravenous clindamycin alone was better than penicillin plus chloramphenicol for treating women with septic abortion. Similarly, available evidence did not suggest that penicillin plus chloramphenicol was better than cephalothin plus kanamycin for the treatment of women with septic abortion. Tetracyline enzyme antibiotic appeared to be more effective than intravenous penicillin G in reducing the time to fever defervescence, but this evidence was provided by only one study at low risk of bias.There is a need for high-quality RCTs providing reliable evidence for treatments of septic abortion with antibiotics that are currently in use. The three included studies were carried out over 30 years ago. There is also a need to include institutions in low-resource settings, such as sub-Saharan Africa, Latin America and the Caribbean, and South Asia, with a high burden of abortion and health systems challenges.

Insights from an expert group meeting on the definition and measurement of unsafe abortion

Until recently, WHO operationally defined unsafe abortion as illegal abortion. In the past decade, however, the incidence of abortion by misoprostol administration has increased in countries with restrictive abortion laws. Access to safe surgical abortions has also increased in many such countries. An important effect of these trends has been that, even in an illegal environment, abortion is becoming safer, and an updated system for classifying abortion in accordance with safety is needed. Numerous factors aside from abortion method or legality should be taken into consideration in developing such a classification system. An Expert Meeting on the Definition and Measurement of Unsafe Abortion was convened in London, UK, on January 9–10, 2014, to move toward developing a classification system that both reflects current conditions and acknowledges the gradient of risk associated with abortion. The experts also discussed the types of research needed to monitor the incidence of abortion at each level of safety. These efforts are urgently needed if we are to ensure that preventing unsafe abortion is appropriately represented on the global public health agenda. Such a classification system would also motivate investment in research to accurately measure and monitor abortion incidence across categories of safety.

The triple threat of pregnancy, HIV infection and malaria: reported causes of maternal mortality in two nationwide health facility assessments in Mozambique, 2007 and 2012

BACKGROUND

The paper's primary purpose is to determine changes in magnitude and causes of institutional maternal mortality in Mozambique. We also describe shifts in the location of institutional deaths and changes in availability of prevention and treatment measures for malaria and HIV infection.

METHODS

Two national cross-sectional assessments of health facilities with childbirth services were conducted in 2007 and 2012. Each collected retrospective data on deliveries and maternal deaths and their causes. In 2007, 2,199 cases of maternal deaths were documented over a 12 month period; in 2012, 459 cases were identified over a three month period. In 2007, data collection also included reviews of maternal deaths when records were available (n = 712).

RESULTS

Institutional maternal mortality declined from 541 to 284/100,000 births from 2007 to 2012. The rate of decline among women dying of direct causes was 66% compared to 26% among women dying of indirect causes. Cause-specific mortality ratios fell for all direct causes. Patterns among indirect causes were less conclusive given differences in cause-of-death recording. In absolute numbers, the combination of antepartum and postpartum hemorrhage was the leading direct cause of death each year and HIV and malaria the main non-obstetric causes. Based on maternal death reviews, evidence of HIV infection, malaria or anemia was found in more than 40% of maternal deaths due to abortion, ectopic pregnancy and sepsis. Almost half (49%) of all institutional maternal deaths took place in the largest hospitals in 2007 while in 2012, only 24% occurred in these hospitals. The availability of antiretrovirals and antimalarials increased in all types of facilities, but increases were most dramatic in health centers.

CONCLUSIONS

The rate at which women died of direct causes in Mozambique's health facilities appears to have declined significantly. Despite a clear improvement in access to antiretrovirals and antimalarials, especially at lower levels of health care, malaria, HIV, and anemia continue to exact a heavy toll on child-bearing women. Going forward, efforts to end preventable maternal and newborn deaths must maximize the use of antenatal care that includes integrated preventive/treatment options for HIV infection, malaria and anemia.

Factors associated with repeat induced abortion in Kenya

BACKGROUND

Over six million induced abortions were reported in Africa in 2008 with over two million induced abortions occurring in Eastern Africa. Although a significant proportion of women in the region procure more than one abortion during their reproductive period, there is a dearth of research on factors associated with repeat abortion.

METHODS

Data for this study come from the Magnitude and Incidence of Unsafe Abortion Study conducted by the African Population and Health Research Center in Kenya in 2012. The study used a nationally-representative sample of 350 facilities (level II to level VI) that offer post-abortion services for complications following induced and spontaneous abortions. A prospective morbidity survey tool was used by health providers in 328 facilities to collect information on socio-demographic charateristics, reproductive health history and contraceptive use at conception for all patients presenting for post-abortion services. Our analysis is based on data recorded on 769 women who were classified as having had an induced abortion.

RESULTS

About 16 % of women seeking post abortion services for an induced abortion reported to have had a previous induced abortion. Being separated or divorced or widowed, having no education, having unwanted pregnancy, having 1-2 prior births and using traditional methods of contraception were associated with a higher likelihood of a repeat induced abortion.

CONCLUSIONS

The findings point to the need to address the reasons why women with first time induced abortion do not have the necessary information to prevent unintended pregnancies and further induced abortions. Possible explanations linked to the quality of post-abortion family planning and coverage of long-acting methods should be explored.

Personal Beliefs and Professional Responsibilities: Ethiopian Midwives' Attitudes toward Providing Abortion Services after Legal Reform

In 2005, Ethiopia liberalized its abortion law and subsequently authorized midwives to offer abortion services. Using a 2013 survey of 188 midwives and 12 interviews with third-year midwifery students, this cross-sectional research examines midwives' attitudes toward abortion to understand their decisions about service provision. Most midwives were willing to provide abortion services. This willingness was positively and significantly related to clinical experience with abortion, but negatively and significantly related to religiosity, belief that providers have the right to refuse to provide services, and care of patients from periurban as opposed to rural areas. No significant relationship was found with perceptions of abortion stigma, years of work as a midwife, or knowledge of the law. Interview data suggest complex dynamics underlying midwives' willingness to offer services, including conflicts between professional norms and religious beliefs. Findings can inform Ethiopia's efforts to reduce maternal mortality through task-shifting to midwives and can aid other countries that are confronting provider shortages and high levels of maternal mortality and morbidity, particularly due to unsafe abortion.

Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states

OBJECTIVE

To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health.

DESIGN

Population-based natural experiment.

SETTING AND DATA SOURCES

Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011.

MAIN OUTCOMES

Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR).

INDEPENDENT VARIABLES

Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence.

MAIN RESULTS

Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (β-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (β=-0.061 to -1.100), skilled attendance at birth (β=-0.032 to -0.427), low birth weight (β=0.149 to 2.166), all-abortion hospitalisation ratio (β=-0.566 to -0.962), clean water (β=-0.048 to -0.730), sanitation (β=-0.052 to -0.758) and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse association with MMR (β=-14.329) and MMRAO (β=-1.750) and a direct association with iAMR (β=1.383). Altogether, these factors accounted for (R(2)) 51-88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates.

CONCLUSIONS

Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states.

Role-players in abortion decision-making in the Accra Metropolis, Ghana

BACKGROUND

Making the final decision to terminate a pregnancy can be influenced by different circumstances involving various individuals. This paper describes the key players involved in the decision-making process regarding abortions among women who elected to undergo an induced abortion in a cosmopolitan urban setting in Ghana.

METHODS

A retrospective cross-sectional mixed method study was conducted between January and December 2011. A total of 401 women with records in abortion logbooks were selected for an interviewer-administered questionnaire and an in-depth interview. Descriptive and multinomial logistic regression analyses were used to assess the quantitative data, and a thematic analysis was applied to the qualitative data.

RESULTS

The findings of the study reveal that pregnant individuals, mothers of abortion-seekers, male partners, and "Others" (for example, friends, employers) were instrumental in making a decision to terminate unplanned/unwanted pregnancies. Several key factors influenced the decision-making processes, including aversion from the men responsible for the pregnancy, concerns about abnormalities/deformities in future births due to unprofessionally conducted abortions, and economic considerations.

CONCLUSION

A number of individuals, such as friends, mothers, and male partners, influence the decision-making process regarding abortion among the participants of the study. Various targeted messages are needed for the various participants in the decision.

Overview of abortion cases with severe maternal outcomes in the WHO Multicountry Survey on Maternal and Newborn Health: a descriptive analysis

OBJECTIVE

To summarise individual and institutional characteristics of abortion-related severe maternal outcomes reported at health facilities.

DESIGN

Secondary analysis of data from the WHO Multicountry Survey on Maternal and Newborn Health.

SETTING

85 health facilities in 23 countries.

SAMPLE

322 women with abortion-related severe maternal outcomes.

METHODS

Frequency distributions and comparisons of differences in characteristics between cases of maternal near miss and death using Fisher's exact tests of association.

MAIN OUTCOME MEASURES

Individual and institutional characteristics and frequencies of potentially life-threatening conditions, and interventions provided to women with severe maternal outcomes, maternal near miss, and maternal death.

RESULTS

Most women with abortion-related severe maternal outcomes (SMOs) were 20-34 years old (65.2%), married or cohabitating (92.3%), parous (84.2%), and presented with abortions resulting from pregnancies at less than 14 weeks of gestation (67.1%). The women who died were younger, more frequently without a partner, and had abortions at ≥14 weeks of gestation, compared with women with maternal near miss (MNM). Curettage was the most common mode of uterine evacuation. The provision of blood products and therapeutic antibiotics were the most common other interventions recorded for all women with abortion-related SMOs; those who died more frequently had antibiotics, laparotomy, and hysterectomy, compared with women with MNM. Although haemorrhage was the most common cause of abortion-related SMO, infection (alone and in combination with haemorrhage) was the most common cause of death.

CONCLUSION

This analysis affirms a number of previously observed characteristics of women with abortion-related severe morbidity and mortality, despite the fact that facility-based data on abortion-related SMO suffers a number of limitations.

Measuring unsafe abortion-related mortality: a systematic review of the existing methods

BACKGROUND

The WHO estimates that 13% of maternal mortality is due to unsafe abortion, but challenges with measurement and data quality persist. To our knowledge, no systematic assessment of the validity of studies reporting estimates of abortion-related mortality exists.

STUDY DESIGN

To be included in this study, articles had to meet the following criteria: (1) published between September 1(st), 2000-December 1(st), 2011; (2) utilized data from a country where abortion is "considered unsafe"; (3) specified and enumerated causes of maternal death including "abortion"; (4) enumerated ≥100 maternal deaths; (5) a quantitative research study; (6) published in a peer-reviewed journal.

RESULTS

7,438 articles were initially identified. Thirty-six studies were ultimately included. Overall, studies rated "Very Good" found the highest estimates of abortion related mortality (median 16%, range 1-27.4%). Studies rated "Very Poor" found the lowest overall proportion of abortion related deaths (median: 2%, range 1.3-9.4%).

CONCLUSIONS

Improvements in the quality of data collection would facilitate better understanding global abortion-related mortality. Until improved data exist, better reporting of study procedures and standardization of the definition of abortion and abortion-related mortality should be encouraged.