Abortion and Maternal Mortality in the Developing World

Pregnancy Desirability and Motivational Readiness for Postpartum Contraceptive Use: Findings from Population-Based Surveys in Eight Sub-Saharan African Countries

This study examined the associations between pregnancy intention and motivational readiness for postpartum contraceptive use. Data for this cross-sectional analysis were derived from nationally representative surveys of the Performance Monitoring and Accountability 2020 (PMA2020) project conducted in eight sub-Saharan African countries. Participants included 9488 nonpregnant women of reproductive age (15-49 years) who had given birth in the last 2 years. Weighted multinomial logistic regression analyses were performed to estimate the odds ratios (OR) and their corresponding 95% confidence intervals (CIs) of the associations of motivational readiness for contraceptive adoption categorized as precontemplation, contemplation, and post-action with pregnancy intention. After adjusting for confounding factors, the findings revealed that women in Côte d'Ivoire and Nigeria who had mistimed pregnancies had significantly higher odds of being in the contemplation vs. precontemplation stage compared to those who had intended pregnancies. Similarly, women who had unwanted pregnancies in Ethiopia were also more likely to be in the contemplation stage. Furthermore, significant differences were observed for women in Burkina Faso, Côte d'Ivoire, and Nigeria regarding the association between mistimed pregnancies and being in the post-action stage. For women who had unwanted pregnancies, this association was significant only in Nigeria. Additionally, the odds of being in the contemplation stage, compared to the post-action stage, for women who had unwanted pregnancies were significantly higher in Ethiopia and Nigeria. These results indicate that recent unintended pregnancies in specific sub-Saharan African countries may motivate women to take action to prevent future unintended pregnancies. The findings underscore the importance of tailored and context-specific approaches in family-planning programs based on the stage of motivational readiness.

A Prospective Multi-centric Study of Acceptance, Insertion and Follow-Up of Postpartum Insertions of IUCD

Purpose of the Study

The unmet need for contraception in the postpartum period is a major challenge in our country. Unintended pregnancies are highest in the first year after birth, and postpartum IUCD insertion is an effective way to counter this problem. This study was planned to build up data for acceptance and follow-up of postpartum IUCD insertions.

Methods

The present study has included data of PPIUCD insertions and follow-up from seven institutions over a period of 6 months. The case recruitment lasted for 3 months, including only those who had PPIUCD insertions in this period, and they were followed up for a period of 6 months. The follow-up of patients was at 6 weeks and 6 months. All issues were addressed including side effects, expulsions, myths surrounding the device, etc., along with routine postnatal care.

Results and Conclusion

There were 5227 deliveries and 1895 insertions. The acceptance rate was 36%, and a follow-up at 6 weeks and 6 months showed up an expulsion rate of approximately 4% and a removal rate of 5%. Overall, at the end of 6 months we have a continuation rate of 90%. This shows that a dedicated approach to postpartum contraception will definitely bring down incidence of unintended pregnancies.

Society for Maternal-Fetal Medicine Special Statement: A critical examination of abortion terminology as it relates to access and quality of care

Legal, institutional, and payer policies regulating reproductive health care lack a shared language with medicine, resulting in great confusion and consternation. This paper critically examines the implications and ramifications of unclear language related to abortion care. Using a case-based approach, we highlight the ways in which language and terminology may affect the quality and accessibility of care. We also address repercussions for providers and patients within their team, institutional, state, and payer landscapes. In particular, we explore the stigmatization of abortion as both a word and a process, the role of caregivers as gatekeepers, the implications of viability as a limit for access, and the hierarchy of deservedness and value. Recognizing the role of language in these discussions is critical to building systems that honor the complexities of patient-centered reproductive decision-making, ensure access to comprehensive reproductive health care including abortion, and center patient autonomy. Healthcare providers are uniquely positioned to facilitate institutional, state, and national landscapes in which pregnant patients are supported in their autonomy and provided with just and equitable reproductive health care.

Health care providers’ perceptions of using misoprostol in the treatment of incomplete abortion in Malawi

Background

In Malawi, abortion is only legal to save a pregnant woman’s life. Treatment for complications after unsafe abortions has a massive impact on the already impoverished health care system. Even though manual vacuum aspiration (MVA) and misoprostol are the recommended treatment options for incomplete abortion in the first trimester, surgical management using sharp curettage is still one of the primary treatment methods in Malawi. Misoprostol and MVA are safer and cheaper, whilst sharp curettage has more risk of complications such as perforation and bleeding and requires general anesthesia and a clinician. Currently, efforts are being made to increase the use of misoprostol in the treatment of incomplete abortions in Malawi. To achieve successful implementation of misoprostol, health care providers’ perceptions on this matter are crucial.

Methods

A qualitative approach was used to explore health care providers’ perceptions of misoprostol for the treatment of incomplete abortion using semi-structured in-depth interviews. Ten health care providers were interviewed at one urban public hospital. Each interview lasted 45 min on average. Health care providers of different cadres were interviewed in March and April 2021, nine months after taking part in a training intervention on the use of misoprostol. Interviews were recorded, transcribed verbatim and analyzed using ‘Systematic Text Condensation’.

Results

The health care providers reported many advantages with the increased use of misoprostol, such as reduced workload, less hospitalization, fewer infections, and task-shifting. Availability of the drug and benefits for the patients were also highlighted as important. However, some challenges were revealed, such as deciding who was eligible for the drug and treatment failure. For these reasons, some health care providers still choose surgical treatment as their primary method.

Conclusion

Findings in this study support the recommendation of increased use of misoprostol as a treatment for incomplete abortion in Malawi, as the health care providers interviewed see many advantages with the drug. To scale up its use, proper training and supervision are essential. A sustainable and predictable supply is needed to change clinical practice.

Plain English Summary

Unsafe abortion is a major contributor to maternal mortality worldwide. Unsafe abortion is the termination of an unintended pregnancy by a person without the required skills or equipment, which might lead to serious complications. In Malawi, post-abortion complications are common, and the maternal mortality ratio is among the highest in the world. Retained products of conception, referred to as an incomplete abortion, are common after spontaneous miscarriages and unsafe induced abortions. There are several ways to treat incomplete abortion, and the drug misoprostol has been successful in the treatment of incomplete abortion in other low-income countries. This study explored perceptions among health care providers using misoprostol to treat incomplete abortions and whether the drug can be fully embraced by Malawian health care professionals. Health personnel at a Malawian hospital were interviewed individually regarding the use of the drug for treating incomplete abortions. This study revealed that health care providers interviewed are satisfied with the increased use of misoprostol. They highlighted several benefits, such as reduced workload and that it enabled task-shifting so that various hospital cadres could now treat patients with incomplete abortions. The health care workers also observed benefits for women treated with the drug compared to other treatments. The challenges mentioned were finding out who was eligible for the drug and drug failure. This study supports scaling up the use of misoprostol in the treatment of incomplete abortions in Malawi; the Ministry of Health and policymakers should support future interventions to increase its use.

Multilevel analysis of factors associated with pregnancy termination in Ethiopia

Background

Pregnancy termination is a major public health issue that affects maternal mortality around the world. So the study aimed to identify factors that are associated with pregnancy termination in Ethiopia.

Methods

Community-based crossectional data came from Ethiopia's Mini Demographic and Health Survey 2019. The current study's sample included women who had their pregnancy terminated (aged 15–49) and had complete information on all factors of interest (N = 8885). The binary logistic regression model investigated the factors that contribute to pregnancy termination in Ethiopia and multilevel logistic regression were used to identify regional variation in Ethiopia.

Results

The current study showed that the prevalence of pregnancy termination in Ethiopia was 8.6%. The likelihood of pregnancy termination in uneducated women was 1.5 times (AOR = 1.479, 95% CI = 1.205–1.816) lower than in women who attended elementary school, 1.5 (AOR = 1.476, 95% CI = 1.107–1.969) lower than Secondary attended women and 1.8 times (AOR = 1.755, 95% CI = 1.270–2.427) lower than Higher school attended women. The likelihood of pregnancy termination in rural women was 0.8 times (AOR = 0.753, 95% CI = 0.573–0.990) higher than in urban women.

Conclusion

The current study showed that there was regional Variation among women in Ethiopia to terminate the pregnancy. The characteristics of education level, place of residency, marital status and contraceptive knowledge are significant and differ between regions of the country. As a result, increasing contraception use and enhancing women's knowledge are the most effective ways to avert the problem.

•

Pregnancy termination is a major public health issue that affects maternal mortality around the world.

•The study aimed to identify factors that are associated with pregnancy termination in Ethiopia.

•Community-based crossectional data came from Ethiopia's Mini Demographic and Health Survey 2019.

•The current study showed that the prevalence of pregnancy termination in Ethiopia was 8.6%.

•The current study showed that there was regional Variation among women in Ethiopia to terminate the pregnancy.

•As a result, increasing contraception use and enhancing women's knowledge are the most effective ways to avert the problem.

Abortion and its correlates among female fisherfolk along Lake Victoria in Uganda

INTRODUCTION

In Uganda, people living in fishing communities tend to engage in high-risk sexual activity which leads to unintended pregnancies that may end in abortions. Abortion has negative social, psychological, and medical impacts. We determined the frequency of abortion and its correlates among female fisher-folk along Lake Victoria in Uganda.

METHODS

A cross-sectional survey was conducted among women aged 15- 49 years from Kigungu and Nsazi fishing communities. Data were collected on socio-demographic characteristics, abortion, and family planning use. Associations between abortion and participant characteristics were assessed using logistic regression models.

RESULTS

Of the 713 women interviewed, 36, 5% were pregnant and 247, 34.6 % were using contraception. Majority (600, 84.2%) of those interviewed reported ever being pregnant. Approximately 45% of the pregnancies were un-intended while a third of those who had ever been pregnant (195, 32.5%) reported having aborted before. Slightly over a third (247, 34.6%) reported currently using or ever using family planning. Women aged 30+ years were more likely to abort compared to those aged 15-29 years (aOR: 2.7; 95% CI: 1.23-5.91). Women who had living children were less likely to abort compared to those who didn't have any living child (aOR: 0.06; 95% CI: 0.01 - 0.17).

CONCLUSION

The rate of abortion among female fisher-folk in Uganda is substantial. Family planning use is still low and unintended pregnancies are common. Abortion risk increased with the age of the mother. Continuous behavioral change communication and optimization of family planning use are recommended to reduce abortions.

Overview and factors associated with pregnancies and abortions occurring in sex workers in Benin

Background

Behavioural and structural factors related to sex work, place female sex workers (FSWs) at high risk of maternal mortality and morbidity (MMM), with a large portion due to unintended pregnancies and abortions. In the African context where MMM is the highest in the world, understanding the frequency and determinants of pregnancy and abortion among FSWs is important in order to meet their sexual and reproductive health needs.

Methods

Data from two Beninese cross-sectional surveys among FSWs aged 18+ (2013, N = 450; 2016, N = 504) were merged. We first performed exploratory univariate analyses to identify factors associated with pregnancy and abortion (p < 0.20) using Generalized Estimating Equations with Poisson regression and robust variance. Multivariate analyses first included all variables identified in the univariate models and backward selection (p ≤ 0.05) was used to generate the final models.

Results

Median age was 39 years (N = 866). The proportion of FSWs reporting at least one pregnancy during sex work practice was 16.4%, of whom 42.3% had more than one. Most pregnancies ended with an abortion (67.6%). In multivariate analyses, younger age, longer duration in sex work, previous HIV testing, having a boyfriend and not using condoms with him were significantly (p < 0.05) associated with more pregnancies.

Conclusion

One FSW out of five had at least one pregnancy during her sex work practice. Most of those pregnancies, regardless of their origin, ended with an abortion. Improving access to various forms of contraception and safe abortion is the key to reducing unintended pregnancies and consequently, MMM among FSWs in Benin.

Knowledge, attitude and practice towards abortion and post abortion care among Egyptian private obstetricians and gynaecologists

OBJECTIVE

To assess the knowledge, attitude, and practice of private obstetricians and gynaecologists towards abortion, post-abortion care, and post-abortion family planning.

PATIENTS AND METHODS

A cross-sectional study, from June 2017 to May 2018, using a self-administered questionnaire of 150 obstetricians/gynaecologists at private clinics, centres, hospitals in Ismailia, Egypt. The questionnaire was composed of four broad sections: section one was about the socio-demographic characteristics of the participants; section two was about physicians' knowledge, attitude and practices regarding abortion; section three was about their attitudes and practices regarding post-abortion family planning and screening for sexually transmitted diseases (STDs) in patients presenting for induced abortion; and section four was about the socio-demographic characteristics of women seeking induced abortion taken from the physicians' views.

RESULTS

Only 15.2% of participants had performed an abortion for unwanted pregnancies at ≤12 weeks vs. 3.8% for unwanted pregnancies >12 weeks' gestation. The most common reason for not performing an abortion was religious prohibition (80.35% vs. 86.6% for unwanted pregnancy ≤12 and > 12 weeks, respectively). Social causes were the most common reason for seeking an induced abortion. None of the physicians used manual vacuum aspiration (MVA) for abortion or had received training in MVA. Post-abortion family planning counselling was offered by 20.5% of physicians, while 13.6% screened for STDs.

CONCLUSIONS

The majority of private obstetricians/gynaecologists in Ismailia, Egypt, do not perform abortions for unwanted pregnancies because of their religious beliefs. Post-abortion screening for STDs and family planning services are not sufficiently integrated into post-abortion care.

Availability, accessibility and utilization of post-abortion care in Sub-Saharan Africa: A systematic review

At the 1994 ICPD, sub-Saharan African (SSA) states pledged, inter alia, to guarantee quality post-abortion care (PAC) services. We synthesized existing research on PAC services provision, utilization and access in SSA since the 1994 ICPD. Generally, evidence on PAC is only available in a few countries in the sub-region. The available evidence however suggests that PAC constitutes a significant financial burden on public health systems in SSA; that accessibility, utilization and availability of PAC services have expanded during the period; and that worrying inequities characterize PAC services. Manual and electrical vacuum aspiration and medication abortion drugs are increasingly common PAC methods in SSA, but poor-quality treatment methods persist in many contexts. Complex socio-economic, infrastructural, cultural and political factors mediate the availability, accessibility and utilization of PAC services in SSA. Interventions that have been implemented to improve different aspects of PAC in the sub-region have had variable levels of success. Underexplored themes in the existing literature include the individual and household level costs of PAC; the quality of PAC services; the provision of non-abortion reproductive health services in the context of PAC; and health care provider-community partnerships.

Differences in Life-Saving Obstetric Hemorrhage Treatments for Women with Abortion Versus Nonabortion Etiologies in Tanzania

Complications from unsafe abortion are among the major causes of preventable maternal morbidity and mortality, which may be compounded by delays and disparities in treatment. We conducted a secondary analysis of women with symptoms of hypovolemic shock secondary to severe obstetric hemorrhage in Tanzania. We compared receipt of three lifesaving interventions among women with abortions versus other maternal hemorrhage etiologies. Interventions included: non-pneumatic anti-shock garment (NASG) (N = 393), blood transfusion (N = 249), and referral to a higher-capacity facility (N = 131). After controlling for severity of disease and other confounders, women with abortion-related hemorrhage and shock had 78 percent decreased odds of receiving NASG (p < 0.001) and 77 percent decreased odds of receiving a blood transfusion (p < 0.001) compared to women with hemorrhage and shock from other etiologies. Our findings suggest that, in Tanzania, women with abortion-related hemorrhage received lower quality of care than women with other hemorrhage etiologies.

Analysis of induced abortion-related complications in women admitted to referral health facilities in Kinshasa, Democratic Republic of the Congo

BACKGROUND

Due to a lack of relevant data on induced abortions in the Democratic Republic of the Congo (DRC), as well as the persistence of maternal deaths in the country, this study aims to analyze the extent and characteristics of induced abortion-related complications in women who were admitted to referral health facilities in Kinshasa, including the duration of hospitalization, the mortality rate due to induced abortion complications and their characteristics, and the deaths that occurred after two days of hospitalization.

METHODS

This is a cross-sectional study on 843 obstetric and gynecological patients who were admitted as emergency cases to five referral health facilities in Kinshasa during 2014. These facilities were selected as being representative of five types of districts in Kinshasa, according to their cultural, socioeconomic, and infrastructural characteristics. Patient data were collected from patient records and analyzed.

RESULTS

From the 843 patients admitted to receive obstetric and gynecological emergency care services in 2014 at the health facilities surveyed, 14.7% (95% CI: 12.4-17.3%) had complications due to induced abortion. These complications were significantly diagnosed in adolescents (p = 0.003) and in single, separated, divorced, or widowed women (p = 0.03). The median duration of hospitalization was nine days, and this period of time was significantly longer for the patients who underwent surgery for pelvic peritonitis due to uterine perforation compared with the patients who underwent Caesarean section/hysterectomy. Furthermore, it was significantly longer for the patients who were treated for other induced-abortion related complications compared with patients treated for spontaneous abortion. The mortality rate related to induced abortions was 5.6% (95% CI: 2.3-11.3%), with an increase in risk of death in the presence of a postabortive pelvic peritonitis-type complication; 42.9% of deaths occurred after two days of hospitalization.

CONCLUSION

The complications of induced abortions are a major public health problem due to their frequency among patients admitted to Kinshasa's referral health facilities, their mortality, and their poor medical management. Therefore, there is a need to understand the reason for its poor medical management in order to provide an adequate intervention program.

Analysis of induced abortion-related complications in women admitted to the Kinshasa reference general hospital: a tertiary health facility, Democratic Republic of the Congo

BACKGROUND

Due to a lack of relevant data on induced abortions in the Democratic Republic of the Congo (DRC) as well as the persistence of maternal deaths in the country, this study aims to analyse the induced abortion-related complications in women who were admitted to the Kinshasa Reference General Hospital (KRGH).

METHODS

This is a cross-sectional study on 368 obstetric and gynecological patients who were admitted, as emergency cases, to the KRGH during 2014. This health facility was selected because it is a tertiary health facility with an obstetric and gynecological emergency unit most used in the city of Kinshasa. Patient data were collected from patient records and analyzed.

RESULTS

From the 368 patients admitted to receive obstetric and gynecological emergency care services in 2014 at the KRGH, 12.2% (95% CI: 9.1-16.1%) had complications due to induced abortion that was significantly diagnosed to adolescents (p <  0.001), single or separated or divorced women or widow(p <  0.001), and to patients with history of one or several induced abortions(p <  0.001). The median duration of hospitalization was ten days and this period of time was significantly longer for the patients who underwent surgery for pelvic peritonitis due to uterine perforation(p <  0.001) compared with the group of patients who underwent Caesarean section/hysterectomy. The mortality rate related to them is 37.8% (95% CI: 23.8-53.5%) with an increase of risk of death in the presence of a post-abortive pelvic peritonitis-type complication, 56.3% of deaths occurred after two days of hospitalization.

CONCLUSION

The complications of induced abortions are a major public health problem due to its frequency among patients admitted to the KRGH, as well as the poor medical management, and mortality percentage related to them. Therefore, there is a need to understand the reason for the poor medical management to fill in and provide an adequate intervention package.

Study protocol: incentives for increased access to comprehensive family planning for urban youth using a benefits card in Uganda. A quasi-experimental study

BACKGROUND

The use of contraception is one of the most cost-effective public health interventions and has the potential to prevent about 30% of maternal and 10% of child deaths in developing countries. Voucher-based initiatives for family planning are an effective and viable means of increasing contraceptive use. In this paper, we present a protocol for a pilot study of a novel incentive, a family planning benefits card (FPBC) program to increase uptake of family planning services among urban poor youth in Uganda while leveraging private sector funding.

METHODS

The study employs both impact and health economic evaluation methods to assess the effect of the FPBC program. We propose a quasi-experimental study design with two separate pre- and post-samples to measure program effectiveness. The main outcome of the impact evaluation is the percentage change in the prevalence of modern contraceptive use and unmet need for contraception. We will also conduct model-based incremental cost-effectiveness and budget impact analyses. The main outcomes of the economic evaluation are the cost per enrolled youth and cost per pregnancy averted, and cost per disability-adjusted life-year (DALY) averted. We will also pilot a corporate social responsibility model of sponsorship for the FPBC program in partnership with local corporations. Budget impact analysis will examine the potential affordability of scaling up the FPBC program and the fiscal implications of this scale up to the corporate social responsibility (CSR) budgets of partner corporations, the government, and the individual taxpayer.

DISCUSSION

In this study, we propose an impact and economic evaluation to establish the proof concept of using a FPBC program to increase uptake of family planning services among urban poor youth in Uganda. The results of this study will present stakeholders in Uganda and internationally with a potentially viable option for corporate-sponsored access to family planning in urban poor communities.

TRIAL REGISTRATION

MUREC1/7 No. 10/05-17. Registered 19th July 2017.

The Role of the Nonpneumatic Antishock Garment in Reducing Blood Loss and Mortality Associated with Post-Abortion Hemorrhage

Maternal mortality attributable to post-abortion hemorrhage is often associated with delays in reaching or receiving definitive care. The nonpneumatic antishock garment (NASG), a low-technology first-aid device, has been shown to decrease blood loss and mortality among women experiencing hypovolemic shock secondary to obstetric hemorrhage etiologies. Women experiencing post-abortion hemorrhage face longer delays in receiving definitive treatment as a result of abortion-related stigma and lack of access to quality abortion care; thus the NASG has the potential to make an even greater impact within this population. We conducted a secondary analysis of data collected in Egypt, Nigeria, Zambia, and Zimbabwe in NASG trials, limiting our analytic sample to women who experienced post-abortion hemorrhage (n = 953). Blood loss significantly decreased when the NASG was added to standard hemorrhage management during the intervention phase, and there was a large, although not statistically significant, 52 percent decrease in mortality during the NASG phase. The results indicate that adding the NASG to post-abortion care among women experiencing severe hemorrhage and hypovolemic shock would decrease blood loss and mortality.

Awareness about postpartum insertion of intrauterine device among antenatal cases

BACKGROUND

In spite of many available contraceptives numerous unwanted and unplanned pregnancies occur. Though the couples desire contraception but are not able to accept it due to their ignorance and misconceptions. Intrauterine Contraceptive Device (IUCD); an effective contraceptive is usually inserted six weeks after delivery. It can be inserted within 48 h of delivery called postpartum insertion for which government has started the program in many states. The study was undertaken to find out the choices about contraception after delivery and awareness about postpartum insertion.

METHODS

The present observational study was conducted in one of the zonal service hospitals. 500 antenatal cases were included in the study. Their choice of contraception after delivery and awareness was determined through a questionnaire. Reasons for refusal of postpartum insertion were recorded. A small sample of staff also was included in the study.

RESULTS

500 cases were included in the study, a large number had decided about contraception; mainly breast feeding supplemented by barrier contraceptive. 94 of 500 were willing for insertion of contraceptive device but not immediately after delivery due to apprehension in general and fear of side effects. Staff's awareness about postpartum insertion was poor.

CONCLUSION

Knowledge and acceptance of postpartum insertion is very low among antenatal women; probably because the concept is new in the community. There is a strong need to increase the knowledge and awareness about this by health education and counseling.

Impact of reproductive laws on maternal mortality: the chilean natural experiment

Improving maternal health and decreasing morbidity and mortality due to induced abortion are key endeavors in developing countries. One of the most controversial subjects surrounding interventions to improve maternal health is the effect of abortion laws. Chile offers a natural laboratory to perform an investigation on the determinants influencing maternal health in a large parallel time-series of maternal deaths, analyzing health and socioeconomic indicators, and legislative policies including abortion banning in 1989. Interestingly, abortion restriction in Chile was not associated with an increase in overall maternal mortality or with abortion deaths and total number of abortions. Contrary to the notion proposing a negative impact of restrictive abortion laws on maternal health, the abortion mortality ratio did not increase after the abortion ban in Chile. Rather, it decreased over 96 percent, from 10.8 to 0.39 per 100,000 live births. Thus, the Chilean natural experiment provides for the first time, strong evidence supporting the hypothesis that legalization of abortion is unnecessary to improve maternal health in Latin America.

Costs and consequences of abortions to women and their households: a cross-sectional study in Ouagadougou, Burkina Faso

Little is known about the costs and consequences of abortions to women and their households. Our aim was to study both costs and consequences of induced and spontaneous abortions and complications. We carried out a cross-sectional study between February and September 2012 in Ouagadougou, the capital city of Burkina Faso. Quantitative data of 305 women whose pregnancy ended with either an induced or a spontaneous abortion were prospectively collected on sociodemographic, asset ownership, medical and health expenditures including pre-referral costs following the patient’s perspective. Descriptive analysis and regression analysis of costs were performed. We found that women with induced abortion were often single or never married, younger, more educated and had earlier pregnancies than women with spontaneous abortion. They also tended to be more often under parents’ guardianship compared with women with spontaneous abortion. Women with induced abortion paid much more money to obtain abortion and treatment of the resulting complications compared with women with spontaneous abortion: US$89 (44 252 CFA ie franc of the African Financial Community) vs US$56 (27 668 CFA). The results also suggested that payments associated with induced abortion were catastrophic as they consumed 15% of the gross domestic product per capita. Additionally, 11–16% of total households appeared to have resorted to coping strategies in order to face costs. Both induced and spontaneous abortions may incur high expenses with short-term economic repercussions on households’ poverty. Actions are needed in order to reduce the financial burden of abortion costs and promote an effective use of contraceptives.

A survey of manual vacuum aspiration's experiences among the new medical graduates in Thailand

BACKGROUND

Despite Thai laws permitting abortion conducted by registered medical practitioners, unsafe abortion still kills and maims Thai women as a result of inadequate access to safe abortion services. Surgical evacuation of the uterus by manual vacuum aspirator (MVA) is a safe and effective technique recommended by the World Health Organization (WHO) guidelines. This study assessed new medical graduates' MVA experiences during their clinical years in medical schools.

METHODS

Cross-sectional questionnaire surveys on all new medical graduates participating in the annual assembly arranged by the Ministry of Public Health in 2010 and 2012 were applied. Descriptive and inferential statistics were employed for data analysis.

RESULTS

The significant minority of new graduates (44% and 43% in 2010 and 2012 batches) had seen but never used MVA. The proportion of graduates who had 'never seen' reduced from 32% in 2010 to 23% in 2012 while the proportion of 'ever used' had noticeably increased from 24% to 34% in corresponding years. Graduates from medical schools outside Bangkok and vicinity and those reporting confidence in their surgical skills tended to have more MVA experience. The 2012 graduation year was also positively related to higher experience on MVA.

CONCLUSION

Though the proportion of graduates who had ever used MVA was still low in 2012, a positive change from that in 2010 was observed. Medical schools outside Bangkok and vicinity provided more opportunities for learning MVA. It is recommended that medical schools, especially in Bangkok and vicinity should provide more MVA learning opportunities for students. Adequate training and regular hands-on MVA practice should be incorporated into a wide range of clinical practice.

Outcome of an intervention to improve the quality of private sector provision of postabortion care in northern Nigeria

The outcomes of an intervention aimed at improving the quality of postabortion care provided by private medical practitioners in 8 states in northern Nigeria are reported. A total of 458 private medical doctors and 839 nurses and midwives were trained to offer high-quality postabortion care, postabortion family planning, and integrated sexually transmitted infection/HIV care. Results showed that among the 17009 women treated over 10 years, there was not a single case of maternal death. In a detailed analysis of 2559 women treated during a 15-month period after the intervention was established, only 33 women experienced mild complications, while none suffered major complications of abortion care. At the same time, there was a reduction in treatment cost and a doubling of the contraceptive uptake by the women. Building the capacity of private medical providers can reduce maternal morbidity and mortality associated with induced abortion in northern Nigeria.

Fundamental discrepancies in abortion estimates and abortion-related mortality: A reevaluation of recent studies in Mexico with special reference to the International Classification of Diseases

In countries where induced abortion is legally restricted, as in most of Latin America, evaluation of statistics related to induced abortions and abortion-related mortality is challenging. The present article reexamines recent reports estimating the number of induced abortions and abortion-related mortality in Mexico, with special reference to the International Classification of Diseases (ICD). We found significant overestimations of abortion figures in the Federal District of Mexico (up to 10-fold), where elective abortion has been legal since 2007. Significant overestimation of maternal and abortion-related mortality during the last 20 years in the entire Mexican country (up to 35%) was also found. Such overestimations are most likely due to the use of incomplete in-hospital records as well as subjective opinion surveys regarding induced abortion figures, and due to the consideration of causes of death that are unrelated to induced abortion, including flawed denominators of live births. Contrary to previous publications, we found important progress in maternal health, reflected by the decrease in overall maternal mortality (30.6%) from 1990 to 2010. The use of specific ICD codes revealed that the mortality ratio associated with induced abortion decreased 22.9% between 2002 and 2008 (from 1.48 to 1.14 deaths per 100,000 live births). Currently, approximately 98% of maternal deaths in Mexico are related to causes other than induced abortion, such as hemorrhage, hypertension and eclampsia, indirect causes, and other pathological conditions. Therefore, only marginal or null effects would be expected from changes in the legal status of abortion on overall maternal mortality rates. Rather, maternal health in Mexico would greatly benefit from increasing access to emergency and specialized obstetric care. Finally, more reliable methodologies to assess abortion-related deaths are clearly required.

Potential cost-effectiveness of universal access to modern contraceptives in Uganda

Background

Over two thirds of women who need contraception in Uganda lack access to modern effective methods. This study was conducted to estimate the potential cost-effectiveness of achieving universal access to modern contraceptives in Uganda by implementing a hypothetical new contraceptive program (NCP) from both societal and governmental (Ministry of Health (MoH)) perspectives.

Methodology/Principal Findings

A Markov model was developed to compare the NCP to the status quo or current contraceptive program (CCP). The model followed a hypothetical cohort of 15-year old girls over a lifetime horizon. Data were obtained from the Uganda National Demographic and Health Survey and from published and unpublished sources. Costs, life expectancy, disability-adjusted life expectancy, pregnancies, fertility and incremental cost-effectiveness measured as cost per life-year (LY) gained, cost per disability-adjusted life-year (DALY) averted, cost per pregnancy averted and cost per unit of fertility reduction were calculated. Univariate and probabilistic sensitivity analyses were performed to examine the robustness of results. Mean discounted life expectancy and disability-adjusted life expectancy (DALE) were higher under the NCP vs. CCP (28.74 vs. 28.65 years and 27.38 vs. 27.01 respectively). Mean pregnancies and live births per woman were lower under the NCP (9.51 vs. 7.90 and 6.92 vs. 5.79 respectively). Mean lifetime societal costs per woman were lower for the NCP from the societal perspective ($1,949 vs. $1,987) and the MoH perspective ($636 vs. $685). In the incremental analysis, the NCP dominated the CCP, i.e. it was both less costly and more effective. The results were robust to univariate and probabilistic sensitivity analysis.

Conclusion/Significance

Universal access to modern contraceptives in Uganda appears to be highly cost-effective. Increasing contraceptive coverage should be considered among Uganda's public health priorities.

Review of postpartum contraceptive practices at Chiang Mai University Hospital: implications for improving quality of service

OBJECTIVE

To evaluate the acceptance rate and patterns of contraceptive use among postpartum women.

SUBJECTS AND METHODS

The records of 1,009 postpartum women attending the Family Planning Clinic at Chiang Mai University Hospital, Thailand, during January to December 2009 were reviewed.

RESULTS

Mean age was 28.2 ± 5.7 years (range 15-48). Almost all 920 women (91.2%) practiced breastfeeding. The acceptance rate of contraception was 97.6%. The types of contraceptive used were: depot medroxyprogesterone acetate, 387 (38.4%); progestin-only pills, 262 (26.0%); tubal resection, 201 (19.9%); male condom, 78 (7.7%); oral combined pills, 49 (4.9%); intrauterine device, 5 (0.5%); implant, 3 (0.3%). Among women undergoing tubal resection, 29 (14.4%) were ≤24 years of age. Significant independent predictors for using long-acting reversible contraception were young age and little or no formal education.

CONCLUSION

The acceptance rate of contraception in this study was high. However, the following issues need to be evaluated: compliance of women using progestin-only pills, awareness of long-acting reversible contraception as an alternative option in women considering sterilization, and interventions to promote the use of intrauterine devices and implants.

Estimating the costs of induced abortion in Uganda: a model-based analysis

BACKGROUND

The demand for induced abortions in Uganda is high despite legal and moral proscriptions. Abortion seekers usually go to illegal, hidden clinics where procedures are performed in unhygienic environments by under-trained practitioners. These abortions, which are usually unsafe, lead to a high rate of severe complications and use of substantial, scarce healthcare resources. This study was performed to estimate the costs associated with induced abortions in Uganda.

METHODS

A decision tree was developed to represent the consequences of induced abortion and estimate the costs of an average case. Data were obtained from a primary chart abstraction study, an on-going prospective study, and the published literature. Societal costs, direct medical costs, direct non-medical costs, indirect (productivity) costs, costs to patients, and costs to the government were estimated. Monte Carlo simulation was used to account for uncertainty.

RESULTS

The average societal cost per induced abortion (95% credibility range) was $177 ($140-$223). This is equivalent to $64 million in annual national costs. Of this, the average direct medical cost was $65 ($49-86) and the average direct non-medical cost was $19 ($16-$23). The average indirect cost was $92 ($57-$139). Patients incurred $62 ($46-$83) on average while government incurred $14 ($10-$20) on average.

CONCLUSION

Induced abortions are associated with substantial costs in Uganda and patients incur the bulk of the healthcare costs. This reinforces the case made by other researchers--that efforts by the government to reduce unsafe abortions by increasing contraceptive coverage or providing safe, legal abortions are critical.

Vital registration in rural Africa: is there a way forward to report on health targets of the Millennium Development Goals?

Vital registration - the systematic recording of births and deaths - has both legal and health significance. In particular, accurate recording and reporting of vital statistics are public goods to enable the monitoring of progress towards achieving health related targets of the 2015 United Nations Millennium Development Goals (MDG). The reality in Africa is that most births and deaths cannot be traced in legal records or official statistics and as such, there is currently no way of assessing progress towards achieving MDG targets and this applies particularly to rural settings in Africa. From the context of a rural district in Malawi, we describe an informal traditional system for the reporting of deaths at village level, and discuss the potential opportunities, challenges and ways forward in the wider implementation and interpretation of vital data generated by such a system. Such a system might provide an interim solution for accelerating the production and use of district level vital statistics for legal, administrative, statistical purposes and to report on the MDG in rural Africa while waiting for more comprehensive national systems to become a reality.

Self-reporting of induced abortion by women attending prenatal clinics in urban Nigeria

OBJECTIVE

To determine the proportion of all clinically confirmed pregnancies that end as induced abortion in a cohort of pregnant women in Nigeria.

METHODS

A total of 490 women who attended prenatal clinics at the University of Benin Teaching Hospital were interviewed with the preceding birth technique (PBT) on the outcomes of their previous pregnancies, including abortions.

RESULTS

Of the 490 women, 384 women (78.4%) reported previous abortions. A total of 1883 previous pregnancies were reported by the women, of which 914 ended in abortion, 545 in live births, and 421 in stillbirths, with 3 unclassified. The total abortion ratio was 914/1842 (49.6%), when 41 women who reported no previous pregnancies were excluded. Of the 914 abortions, 751 (82.25) were induced abortions, 146 (16.0%) were spontaneous abortions, 9 (0.98%) were missed abortions, and 8 were unclassified. Results of logistic regression analysis showed that women aged 25-29 years were 4 times more likely to report induced abortion compared with older women.

CONCLUSION

Induced abortion was found to be highly prevalent in this region of Nigeria, according to self-reports of women who were asked questions on abortion in the context of medical care.

Morbidity and mortality due to unsafe abortion in Pakistan

OBJECTIVES

To determine the frequency of women who had undergone an unsafe abortion and attended a tertiary care hospital in Pakistan with complications.

METHODS

Patients with a history of termination at a gestational age of less than or equal to 22 weeks were included in the study.

RESULTS

Of 230 women who met the inclusion criteria, 50 (21.7%) patients had undergone an unsafe abortion and attended the hospital with associated complications. Unintended pregnancy was the reason for the abortion in 82% of women (n=41). Eighteen (36%) underwent terminations performed by doctors, 18 (36%) by Lady Health Visitors (n=18), 10 (20%) by an untrained birth attendant (Dai), and 4 (8.0%) by nurses. Dilatation and evacuation procedures were performed in 28 (56.0%) women, while a Laminaria tent prior to evacuation was used in 18 (36.0%). Major complications included uterine perforation and gastrointestinal injury, observed in 27 (54.0%) women. Hemorrhage was observed in 13 (26.0%) women with retained products of conception after incomplete abortion. Six (12.0%) women died.

CONCLUSION

Healthcare providers performed the majority of terminations. To prevent maternal mortality, improved skills through refresher courses and workshops on safer methods are needed.

Progress towards the Millennium Development Goals: a long trek for reproductive health

With only six years remaining to achieve the Millennium Development Goals in 2015, issues pertaining to universal access to reproductive health deserve more emphasis as part of current efforts in international health. The maternal health goal is the Millennium Development Goal with the most disappointing progress. Whereas much has been achieved globally for the utilization of family planning services, there are some geographical areas and subpopulations where progress is lacking. Health systems should be strengthened whilst addressing disparities. The rights and gender aspects of reproductive health have been fully documented, but equitable access and economic aspects should be considered in policy formulation and program implementation. Advocacy is needed for key players to leverage support, whereas efforts for accelerating progress should be sustainable in the long term.