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Heffron R, Casmir E, Aswani L, Ngure K, Kwach B, Ogello V, Kiptinness C, Ambiyo F, Wairimu N, Ossome E, Machafu H, Zia Y, Thomas D, Scoville C, Barker T, Bukusi E, Mugo N. HIV risk and pre-exposure prophylaxis interest among women seeking post-abortion care in Kenya: a cross-sectional study. J Int AIDS Soc 2021; 24:e25703. [PMID: 33973355 PMCID: PMC8110894 DOI: 10.1002/jia2.25703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/11/2021] [Accepted: 03/23/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Post-abortion clinics located in regions with high HIV burden may ideal locations to integrate counselling and delivery of HIV pre-exposure prophylaxis (PrEP), aligning with normative goals for integrated delivery of HIV and reproductive health care. The objective of this study was to gauge the degree to which Kenyan women seeking care for a pregnancy loss, including induced abortion, are at risk for HIV and whether women would welcome an introduction to PrEP prior to discharge from post-abortion care. METHODS We conducted a mixed-methods study from August 2019 to February 2020 with women ages 15 to 30 recruited sequentially as they were accessing post-abortion care at public and private facilities in Thika and Kisumu, Kenya. Data collection was through a cross-sectional survey and laboratory testing for common sexually transmitted infections (N = 200), and in-depth interviews (N = 30). Descriptive statistics summarize PrEP knowledge and referrals and a multivariable log-link binomial model estimated correlates of receiving a referral for PrEP. Qualitative data were analysed using inductive and deductive approaches. RESULTS Among 200 HIV-negative women (median age 21.0, interquartile range 19.0 to 22.0), the prevalence of Chlamydia trachomatis was 18.2% and Neisseria gonorrhoeae was 2.0%. Half of the women scored ≥5 on a validated tool that would correspond to an expected HIV incidence of 9.5% per year. Approximately half (55.8%) of women were familiar with PrEP prior to the study and 33.3% received a referral from study staff to a clinic offering PrEP. In qualitative interviews, women expressed interest in accessing PrEP from the gynaecology ward that provided post-abortion care but they preferred alternative locations for PrEP refills. CONCLUSIONS Kenyan women accessing post-abortion care have substantial HIV risk and were favourable about the idea of receiving support to initiate PrEP as part of care offered during post-abortion care. These settings can be integrated into national PrEP programmes as locations providing PrEP referrals and initiation.
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Affiliation(s)
- Renee Heffron
- Department of Global HealthUniversity of WashingtonSeattleUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Edinah Casmir
- Partners in Health and Research DevelopmentThikaKenya
- Center for Clinical ResearchKenya Medical Research InstituteNairobiKenya
| | - Linda Aswani
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Kenneth Ngure
- Jomo Kenyatta University of Agriculture and TechnologyNairobiKenya
| | - Benn Kwach
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Vallery Ogello
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | | | - Faith Ambiyo
- Partners in Health and Research DevelopmentThikaKenya
| | - Njeri Wairimu
- Partners in Health and Research DevelopmentThikaKenya
| | - Ethel Ossome
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Hilda Machafu
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Yasaman Zia
- Department of Global HealthUniversity of WashingtonSeattleUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Dorothy Thomas
- Department of Global HealthUniversity of WashingtonSeattleUSA
| | | | | | - Elizabeth Bukusi
- Department of Global HealthUniversity of WashingtonSeattleUSA
- Department of Obstetrics and GynecologyUniversity of WashingtonSeattleUSA
| | - Nelly Mugo
- Department of Global HealthUniversity of WashingtonSeattleUSA
- Partners in Health and Research DevelopmentThikaKenya
- Center for Clinical ResearchKenya Medical Research InstituteNairobiKenya
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Espinoza C, Samandari G, Andersen K. Abortion knowledge, attitudes and experiences among adolescent girls: a review of the literature. Sex Reprod Health Matters 2020; 28:1744225. [PMID: 32284012 PMCID: PMC7888105 DOI: 10.1080/26410397.2020.1744225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Adolescent girls comprise a considerable proportion of annual abortion deaths, worldwide, with 15% of all unsafe abortions taking place among girls under 20 years of age. Despite recent global attention to the health and welfare of adolescent girls, little is known about their abortion experience, particularly of those under the age of 15 years. This review examines existing peer-reviewed and grey literature on abortion-related experiences of adolescent girls, paying particular attention to girls ages 10-14. In December 2019, the authors conducted a comprehensive search of five major online resource databases, using a two-part keyword search strategy for articles from 2003 to 2019. Of the original 3,100+ articles, 1,228 were individually screened and 35 retained for inclusion in the analysis. Findings show that while adolescent girls may have knowledge of abortion in general, they lack specific knowledge of sources of care and delay care-seeking due to the fear of stigma, lack of resources and provider bias. Adolescent girls do not experience higher rates of physical complications compared to older cohorts, but they are at risk of psychosocial harm. For girls ages 10-14, abortion experience may be compounded by pregnancy due to sexual abuse or transactional sex, and they face even more barriers to care than older adolescents in terms of provider bias and lack of agency. Adolescents have unique needs and experiences around abortion, which should be accounted for in programming and advocacy. Adolescent girls need information about safe abortion at an early age and a responsive and stigma-free health system.
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Affiliation(s)
- Cecilia Espinoza
- Ipas Senior Advocacy Advisor, Ipas, Chapel Hill, North Carolina, USA
| | | | - Kathryn Andersen
- Chief Scientific and Technical Officer, Ipas, Chapel Hill, North Carolina, USA
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Tesfaye B, Tewabe M, Ferede A, Dawson A. Induced Second Trimester Abortion and Associated Factors at Debre Markos Referral Hospital: Cross-Sectional Study. WOMEN'S HEALTH (LONDON, ENGLAND) 2020; 16:1745506520929546. [PMID: 32578513 PMCID: PMC7315676 DOI: 10.1177/1745506520929546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 04/21/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although most induced abortions in Ethiopia are performed in the first trimester, many women will still require second trimester abortions. While access to abortion in Ethiopia is limited, few data are being available concerning the demand for and associated outcomes of second trimester abortions. This knowledge is important for planning the health service response to abortion. OBJECTIVE The main objective of this study was to determine the proportion and associated factors of second trimester abortion among women presenting for abortion care services at Debre Markos Referral Hospital, Debre Markos, Northwest Ethiopia. METHODS An institution-based cross-sectional study was conducted at Debre Markos Referral Hospital on a sample of 262 calculated using the single population proportion formula. Women who sought abortion services were interviewed consecutively from 12 February 2017 to 14 March 2017. Data were collected in a face-to-face exit interview and document review and analyzed using SPSS version 24.0 software. Bivariate and multivariable analyses were undertaken to identify factors. RESULT Of the women who presented for abortion care services in Debre Markos Referral Hospital, 73 (29.6%) had induced second trimester abortion. Unmarried women (adjusted odds ratio = 4.93, 95% confidence interval = 1.41-17.16) and women employed at private business (adjusted odds ratio = 6.17, 95% confidence interval = 1.16-32.76) were associated with induced second trimester abortion. CONCLUSION This study revealed that almost one-third of women who presented for abortion care services at Debre Markos Referral Hospital had induced second trimester abortions. Raising awareness of the health consequence of second trimester abortion at community levels and counseling to avoid further occurrences are helpful to minimize the problem. Furthermore, early management of induced second trimester abortion is very crucial to prevent further complications.
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Affiliation(s)
- Bekele Tesfaye
- Department of Nursing, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Mesenbet Tewabe
- Department of Medicine, School of Medicine, Debre Markos University, Debre Markos, Ethiopia
| | - Aster Ferede
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Angela Dawson
- The Australian Centre for Public and Population Health Research (ACPPHR), Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
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Izugbara C, Wekesah FM, Sebany M, Echoka E, Amo-Adjei J, Muga W. Availability, accessibility and utilization of post-abortion care in Sub-Saharan Africa: A systematic review. Health Care Women Int 2019; 41:732-760. [PMID: 31855511 DOI: 10.1080/07399332.2019.1703991] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
| | | | - Meroji Sebany
- International Center for Research on Women, Washington, D.C, USA
| | - Elizabeth Echoka
- Centre for Public Health Research, Kenya Medical Research Institute - KEMRI, Nairobi, Kenya
| | - Joshua Amo-Adjei
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
| | - Winstoun Muga
- African Population & Health Research Center, Nairobi, Kenya
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Irinyenikan TA, Loto OM, Oluborode B, Awowole I, Bello FA, Fabamwo AO, Guest P, Ganatra B, Fawole B. A prospective study of severity of complications associated with use of misoprostol and other abortion methods in South West Nigeria. Int J Gynaecol Obstet 2019; 146:302-307. [PMID: 31152593 DOI: 10.1002/ijgo.12877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 02/15/2019] [Accepted: 05/30/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess the severity of complications following misoprostol used to induce abortion compared with other methods among women admitted for postabortion complications. METHODS A cross-sectional study of women who presented with complications of induced abortion at nine secondary and tertiary hospitals in South West Nigeria between April 1, 2013 and May 31, 2014. Face-to-face interviews were conducted and information on the current admission was extracted from patient records. Associations between abortion method used and severity of abortion complications were evaluated using χ2 and Fisher exact tests. RESULTS Of 522 women included in the study, 177 reported an induced abortion: 41 women (23.2%) had used misoprostol at the first attempt to induce abortion, whereas 79 (44.6%) women had undergone surgical abortion. Occurrence of fever (P=0.06), bleeding (P=0.3), and lower abdominal pain (P=0.32) was not significantly different between the misoprostol and surgical abortion/other methods groups. Severe complications were rare with misoprostol, but more common among women in the surgical abortion/other methods group. Maternal mortality occurred only among women in the surgical abortion/other methods group. CONCLUSION Use of misoprostol for induced abortion was associated with fewer complications and no maternal mortality compared with surgical abortion/other methods.
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Affiliation(s)
| | - Olabisi M Loto
- Department of Obstetrics and Gynecology, Obafemi Awolowo University Teaching Hospital Complex, Ilesha, Nigeria
| | - Babawale Oluborode
- Department of Obstetrics and Gynecology, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Ibraheem Awowole
- Department of Obstetrics and Gynecology, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Folasade A Bello
- Department of Obstetrics and Gynecology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Adetokunbo O Fabamwo
- Department of Obstetrics and Gynecology, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
| | - Philip Guest
- Institute for Population and Social Research, Salaya, Bangkok, Thailand
| | - Bela Ganatra
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), WHO, Geneva, Switzerland
| | - Bukola Fawole
- Department of Obstetrics and Gynecology, College of Medicine, University of Ibadan, Ibadan, Nigeria
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Calvert C, Owolabi OO, Yeung F, Pittrof R, Ganatra B, Tunçalp Ö, Adler AJ, Filippi V. The magnitude and severity of abortion-related morbidity in settings with limited access to abortion services: a systematic review and meta-regression. BMJ Glob Health 2018; 3:e000692. [PMID: 29989078 PMCID: PMC6035513 DOI: 10.1136/bmjgh-2017-000692] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/21/2018] [Accepted: 05/24/2018] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Clara Calvert
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Felicia Yeung
- School of Medicine, King’s College London, London, UK
| | | | - Bela Ganatra
- Department of Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Özge Tunçalp
- Department of Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Alma J Adler
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Veronique Filippi
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Araújo TVBD, Aquino EML, Menezes GMS, Alves MTSSDBE, Almeida MDCC, Alves SV, Coimbra L, Campbell OMR. Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil. CAD SAUDE PUBLICA 2018; 34:e00168116. [PMID: 29952404 DOI: 10.1590/0102-311x00168116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/04/2017] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
| | - Estela M L Aquino
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brasil
| | - Greice M S Menezes
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brasil
| | | | | | | | | | - Oona M R Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, U.K
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Aantjes CJ, Gilmoor A, Syurina EV, Crankshaw TL. The status of provision of post abortion care services for women and girls in Eastern and Southern Africa: a systematic review. Contraception 2018; 98:S0010-7824(18)30094-5. [PMID: 29550457 DOI: 10.1016/j.contraception.2018.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 03/04/2018] [Accepted: 03/05/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To conduct a systematic review of the status of post-abortion care (PAC) provision in Eastern and Southern Africa with particular reference to reach, quality and costs of these services. STUDY DESIGN We searched Pubmed, EMBASE, Science Direct, POPLINE and Web of Science for articles published between 2000 and October 2017 presenting primary or secondary data from one or more countries in the region. RESULTS Seventy articles representing data from fourteen countries were abstracted and included in the review. Implementation of PAC services was found to be patchy across countries for which data was available. However, there is evidence of efforts to introduce PAC at lower level health facilities, to use mid-level providers and to employ less invasive medical techniques. Eleven countries from the region were not represented in this review, exposing a considerable knowledge gap over the state of PAC in the region. The disparate access for rural women and girls, the suboptimal service quality and the neglect of adolescent-specific needs were critical gaps in the current PAC provision. CONCLUSION PAC provision and research in this domain cannot be detached from the broader legal and societal context, as social stigma constitutes a major blockage to the advancement of the service. Adolescent girls are a particularly vulnerable and underserved group in the region. IMPLICATIONS The next generation research on PAC should favor multi-country and interdisciplinary study designs with a view to understanding inter-regional differences and supporting advancement towards universal access of PAC by 2030.
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Affiliation(s)
- Carolien J Aantjes
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban.
| | - Andrew Gilmoor
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Science, Vrije Universiteit Amsterdam
| | - Elena V Syurina
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Science, Vrije Universiteit Amsterdam
| | - Tamaryn L Crankshaw
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban
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Madziyire MG, Polis CB, Riley T, Sully EA, Owolabi O, Chipato T. Severity and management of postabortion complications among women in Zimbabwe, 2016: a cross-sectional study. BMJ Open 2018; 8:e019658. [PMID: 29440163 PMCID: PMC5829940 DOI: 10.1136/bmjopen-2017-019658] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Abortion complications cause significant morbidity and mortality. We aimed to assess the severity and factors associated with abortion complications (induced or spontaneous), and the management of postabortion care (PAC) in Zimbabwe. DESIGN Prospective, facility-based 28 day survey among women seeking PAC and their providers. SETTING 127 facilities in Zimbabwe with the capacity to provide PAC, including all central and provincial hospitals, and a sample of primary health centres (30%), district/general/mission hospitals (52%), private (77%) and non-governmental organisation (NGO) (68%) facilities. PARTICIPANTS 1002 women presenting with abortion complications during the study period. MAIN OUTCOME MEASURES Severity of abortion complications and associated factors, delays in care seeking, and clinical management of complications. RESULTS Overall, 59% of women had complications classified as mild, 19% as moderate, 19% as severe, 3% as near miss and 0.2% died. A median of 47 hours elapsed between experiencing complication and receiving treatment; many delays were due to a lack of finances. Women who were rural, younger, not in union, less educated, at later gestational ages or who had more children were significantly more likely to have higher severity complications. Most women were treated by doctors (91%). The main management procedure used was dilatation and curettage/dilatation and evacuation (75%), while 12% had manual vacuum aspiration (MVA) or electrical vacuum aspiration and 11% were managed with misoprostol. At discharge, providers reported that 43% of women received modern contraception. CONCLUSION Zimbabwean women experience considerable abortion-related morbidity, particularly young, rural or less educated women. Abortion-related morbidity and concomitant mortality could be reduced in Zimbabwe by liberalising the abortion law, providing PAC in primary health centres, and training nurses to use medical evacuation with misoprostol and MVA. Regular in-service training on PAC guidelines with follow-up audits are needed to ensure compliance and availability of equipment, supplies and trained staff.
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Affiliation(s)
- Mugove Gerald Madziyire
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | | | | | | | - Tsungai Chipato
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
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Makenzius M, Oguttu M, Klingberg-Allvin M, Gemzell-Danielsson K, Odero TMA, Faxelid E. Post-abortion care with misoprostol - equally effective, safe and accepted when administered by midwives compared to physicians: a randomised controlled equivalence trial in a low-resource setting in Kenya. BMJ Open 2017; 7:e016157. [PMID: 29018067 PMCID: PMC5652492 DOI: 10.1136/bmjopen-2017-016157] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of midwives administering misoprostol to women with incomplete abortion seeking post-abortion care (PAC), compared with physicians. DESIGN A multicentre randomised controlled equivalence trial. The study was not masked. SETTINGS Gynaecological departments in two hospitals in a low-resource setting, Kenya. POPULATION Women (n=1094) with incomplete abortion in the first trimester, seeking PAC between 1 June 2013 to 31 May 2016. Participants were randomly assigned to receive treatment from midwives or physicians. 409 and 401 women in the midwife and physician groups, respectively, were included in the per-protocol analysis. INTERVENTIONS 600 µg misoprostol orally, and contraceptive counselling by a physician or midwife. MAIN OUTCOME MEASURES Complete abortion not needing surgical intervention within 7-10 days. The main outcome was analysed on the per-protocol population with a generalised estimating equation model. The predefined equivalence range was -4% to 4%. Secondary outcomes were analysed descriptively. RESULTS The proportion of complete abortion was 94.8% (768/810): 390 (95.4%) in the midwife group and 378 (94.3%) in the physician group. The proportion of incomplete abortion was 5.2% (42/810), similarly distributed between midwives and physicians. The model-based risk difference for midwives versus physicians was 1.0% (-4.1 to 2.2). Most women felt safe (97%; 779/799), and 93% (748/801) perceived the treatment as expected/easier than expected. After contraceptive counselling the uptake of a contraceptive method after 7-10 days occurred in 76% (613/810). No serious adverse events were recorded. CONCLUSIONS Treatment of incomplete abortion with misoprostol provided by midwives is equally effective, safe and accepted by women as when administered by physicians in a low-resource setting. Systematically provided contraceptive counselling in PAC is effective to mitigate unmet need for contraception. TRIAL REGISTRATION NUMBER NCT01865136; Results.
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Affiliation(s)
- Marlene Makenzius
- Department of Public Health Sciences Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Monica Oguttu
- Kisumu Medical and Education Trust (KMET), Reproductive Health, Kisumu, Kenya
| | - Marie Klingberg-Allvin
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
- Department of Women ´s and Children ´s Health, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Gemzell-Danielsson
- Division of Obstetrics and Gynaecology, Karolinska University Hospital, Stockholm, Sweden
- Departement of Women ´s and Children ´s Health, Karolinska Institutet, Stockholm, Sweden
| | - Theresa M A Odero
- College of Health Sciences, School of Nursing Sciences, University of Nairobi, Nairobi, Kenya
| | - Elisabeth Faxelid
- Department of Public Health Sciences Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
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Zimmerman MS. Reproductive health information needs and maternal literacy in the developing world. IFLA JOURNAL-INTERNATIONAL FEDERATION OF LIBRARY ASSOCIATIONS 2017. [DOI: 10.1177/0340035217713227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
This article provides an analysis of the relationship of literacy and education in the developing world as they intertwine with reproductive health, and explores the reproductive health-related informational needs of women from these regions. Every day more than 800 women die from causes relating to pregnancy, 99% of whom are in the developing world. In 2015 16,000 children under five died every day. This article first provides a systematized review of the extensive canon of literature that explores the relationship between maternal literacy and mother and child health. A content analysis is conducted with the aim of deciphering the reproductive health-related informational needs of women in the developing world. Following, there is a discussion of interventions that have demonstrated success at ameliorating these gaps. Some of these interventions have met information needs related to family planning, HIV/AIDS, sexually transmitted infections, violence against women, sexuality, pregnancy education, and emergency obstetric care.
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Owolabi OO, Cresswell JA, Vwalika B, Osrin D, Filippi V. Incidence of abortion-related near-miss complications in Zambia: cross-sectional study in Central, Copperbelt and Lusaka Provinces. Contraception 2017; 95:167-174. [DOI: 10.1016/j.contraception.2016.08.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 06/29/2016] [Accepted: 08/28/2016] [Indexed: 11/27/2022]
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Melese T, Habte D, Tsima BM, Mogobe KD, Chabaesele K, Rankgoane G, Keakabetse TR, Masweu M, Mokotedi M, Motana M, Moreri-Ntshabele B. High Levels of Post-Abortion Complication in a Setting Where Abortion Service Is Not Legalized. PLoS One 2017; 12:e0166287. [PMID: 28060817 PMCID: PMC5217963 DOI: 10.1371/journal.pone.0166287] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 10/26/2016] [Indexed: 11/17/2022] Open
Abstract
Background Maternal mortality due to abortion complications stands among the three leading causes of maternal death in Botswana where there is a restrictive abortion law. This study aimed at assessing the patterns and determinants of post-abortion complications. Methods A retrospective institution based cross-sectional study was conducted at four hospitals from January to August 2014. Data were extracted from patients’ records with regards to their socio-demographic variables, abortion complications and length of hospital stay. Descriptive statistics and bivariate analysis were employed. Result A total of 619 patients’ records were reviewed with a mean (SD) age of 27.12 (5.97) years. The majority of abortions (95.5%) were reported to be spontaneous and 3.9% of the abortions were induced by the patient. Two thirds of the patients were admitted as their first visit to the hospitals and one third were referrals from other health facilities. Two thirds of the patients were admitted as a result of incomplete abortion followed by inevitable abortion (16.8%). Offensive vaginal discharge (17.9%), tender uterus (11.3%), septic shock (3.9%) and pelvic peritonitis (2.4%) were among the physical findings recorded on admission. Clinically detectable anaemia evidenced by pallor was found to be the leading major complication in 193 (31.2%) of the cases followed by hypovolemic and septic shock 65 (10.5%). There were a total of 9 abortion related deaths with a case fatality rate of 1.5%. Self-induced abortion and delayed uterine evacuation of more than six hours were found to have significant association with post-abortion complications (p-values of 0.018 and 0.035 respectively). Conclusion Abortion related complications and deaths are high in our setting where abortion is illegal. Mechanisms need to be devised in the health facilities to evacuate the uterus in good time whenever it is indicated and to be equipped to handle the fatal complications. There is an indication for clinical audit on post-abortion care to insure implementation of standard protocol and reduce complications.
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Affiliation(s)
- Tadele Melese
- Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana
| | - Dereje Habte
- Consultant Public Health Specialist, Addis Ababa, Ethiopia
| | - Billy M Tsima
- Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana
| | | | - Kesegofetse Chabaesele
- Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana
| | - Goabaone Rankgoane
- Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana
| | | | | | - Mosidi Mokotedi
- School of Nursing, University of Botswana, Gaborone, Botswana
| | - Mpho Motana
- School of Nursing, University of Botswana, Gaborone, Botswana
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Kim CR, Tunçalp Ö, Ganatra B, Gülmezoglu AM. WHO Multi-Country Survey on Abortion-related Morbidity and Mortality in Health Facilities: study protocol. BMJ Glob Health 2016; 1:e000113. [PMID: 28588967 PMCID: PMC5321365 DOI: 10.1136/bmjgh-2016-000113] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/19/2016] [Accepted: 08/30/2016] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Caron R Kim
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Bela Ganatra
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Ahmet Metin Gülmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, WHO, Geneva, Switzerland
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Yegon EK, Kabanya PM, Echoka E, Osur J. Understanding abortion-related stigma and incidence of unsafe abortion: experiences from community members in Machakos and Trans Nzoia counties Kenya. Pan Afr Med J 2016; 24:258. [PMID: 27800111 PMCID: PMC5075459 DOI: 10.11604/pamj.2016.24.258.7567] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 07/15/2016] [Indexed: 11/11/2022] Open
Abstract
Introduction The rate of unsafe abortions in Kenya has increased from 32 per 1000 women of reproductive age in 2002 to 48 per 1000 women in 2012. This is one of the highest in Sub-Saharan Africa. In 2010, Kenya changed its Constitution to include a more enabling provision regarding the provision of abortion services. Abortion-related stigma has been identified as a key driver in silencing women's ability to reproductive choice leading to seeking to unsafe abortion. We sought to explore abortion-related stigma at the community level as a barrier to women realizing their rights to a safe, legal abortion and compare manifestations of abortion stigma at two communities from regions with high and low incidence of unsafe abortion. Methods A qualitative study using 26 focus group discussions with general community members in Machakos and Trans Nzoia Counties. We used thematic and content analysis to analyze and compare community member's responses regarding abortion-related stigma. Results Although abortion is recognized as being very common within communities, community members expressed various ways that stigmatize women seeking an abortion. This included being labeled as killers and are perceived to be a bad influence for women especially young women. Women reported that they were poorly treated by health providers in health facilities for seeking abortion especially young unmarried women. Institutionalization of stigma especially when Ministry of Health withdrew of standards and guidelines only heightened how stigma presents at the facilities and drives women seeking an abortion to traditional birth attendants who offer unsafe abortions leading to increased morbidity and mortality as a result of abortion-related complications. Conclusion Community members located in counties in regions with high incidence of unsafe abortion also reported higher levels of how they would stigmatize a woman seeking an abortion compared to community members from counties in low incidence region. Young unmarried women bore the brunt of being stigmatized. They reported a lack of a supportive environment that provides guidance on correct information on how to prevent unwanted pregnancy and where to get help. Abortion-related stigma plays a major role in women's decision on whether to have a safe or unsafe abortion.
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Affiliation(s)
- Erick Kiprotich Yegon
- Ipas Africa Alliance Nairobi, Kenya; Institute of Tropical Medicine, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi
| | - Peter Mwaniki Kabanya
- Institute of Tropical Medicine, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi
| | - Elizabeth Echoka
- Institute of Tropical Medicine, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi; Kenya Medical Research Institute, Nairobi, Kenya
| | - Joachim Osur
- Amref Health Africa Headquarters, Nairobi, Kenya
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Women's perceptions about abortion in their communities: perspectives from western Kenya. REPRODUCTIVE HEALTH MATTERS 2015; 22:149-58. [PMID: 24908466 DOI: 10.1016/s0968-8080(14)43758-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Unsafe abortion in Kenya is a leading cause of maternal morbidity and mortality. In October 2012, we sought to understand the methods married women aged 24-49 and young, unmarried women aged ≤ 20 used to induce abortion, the providers they utilized and the social, economic and cultural norms that influenced women's access to safe abortion services in Bungoma and Trans Nzoia counties in western Kenya. We conducted five focus groups with young women and five with married women in rural and urban communities in each county. We trained local facilitators to conduct the focus groups in Swahili or English. All focus groups were audiotaped, transcribed, translated, computerized, and coded for analysis. Abortion outside public health facilities was mentioned frequently. Because of the need for secrecy to avoid condemnation, uncertainty about the law, and perceived higher cost of safer abortion methods, women sought unsafe abortions from community midwives, drug sellers and/or untrained providers at lower cost. Many groups believed that abortion was safer at higher gestational ages, but that there was no such thing as a safe abortion method. Our aim was to inform the design of a community-based intervention on safe abortion for women. Barriers to seeking safe services such as high cost, perceived illegality, and fear of insults and abuse at public facilities among both age groups must be addressed.
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Mutua MM, Maina BW, Achia TO, Izugbara CO. Factors associated with delays in seeking post abortion care among women in Kenya. BMC Pregnancy Childbirth 2015; 15:241. [PMID: 26445973 PMCID: PMC4597436 DOI: 10.1186/s12884-015-0660-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 09/16/2015] [Indexed: 11/18/2022] Open
Abstract
Background Delays in seeking quality post abortion care services remain a major contributor to high levels of mortality and morbidity among women who experience unsafe abortion. However, little is known about the causes of and factors associated with delays in seeking care among women who suffer complications of unsafe abortion. This study looks at factors that are associated with delays in seeking post-abortion care among women in Kenya. Methods Data for this study were from a nationally representative sample of 350 healthcare facilities that participated in the 2012 Incidence and Magnitude of Unsafe Abortion study in Kenya. Data included socio-demographic characteristics, reproductive health and clinical histories from all women treated with PAC during a one-month data collection period. Results Delay in seeking care was associated with women’s age, education level, contraceptive history, fertility intentions and referral status. Conclusions There is need to improve women’s access to quality sexual and reproductive health information and services, contraception and abortion care. Improving current PAC services at lower level facilities will also minimize delays resulting from long referral processes.
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Affiliation(s)
- Michael M Mutua
- African Population and Health Research Center, 2nd Floor APHRC Campus, Manga Close Off Kirawa Road, P.O. Box 10787-00100, Nairobi, Kenya. .,School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
| | - Beatrice W Maina
- African Population and Health Research Center, 2nd Floor APHRC Campus, Manga Close Off Kirawa Road, P.O. Box 10787-00100, Nairobi, Kenya.
| | - Thomas O Achia
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
| | - Chimaraoke O Izugbara
- African Population and Health Research Center, 2nd Floor APHRC Campus, Manga Close Off Kirawa Road, P.O. Box 10787-00100, Nairobi, Kenya.
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Mellerup N, Sørensen BL, Kuriigamba GK, Rudnicki M. Management of abortion complications at a rural hospital in Uganda: a quality assessment by a partially completed criterion-based audit. BMC WOMENS HEALTH 2015; 15:76. [PMID: 26388296 PMCID: PMC4576397 DOI: 10.1186/s12905-015-0233-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 09/03/2015] [Indexed: 11/23/2022]
Abstract
Background Complications of unsafe abortion are a major contributor to maternal deaths in developing countries. This study aimed to evaluate the clinical assessment for life-threatening complications and the following management in women admitted with complications from abortions at a rural hospital in Uganda. Methods A partially completed criterion-based audit was conducted comparing actual to optimal care. The audit criteria cover initial clinical assessment of vital signs and management of common severe complications such as sepsis and haemorrhage. Sepsis shall be managed by immediate evacuation of the uterus and antibiotics in relation to and after surgical management. Shock by aggressive rehydration followed by evacuation. In total 238 women admitted between January 2007 and April 2012 were included. Complications were categorized as incomplete, threatened, inevitable, missed or septic abortion and by trimester. Actual management was compared to the audit criteria and presented by descriptive statistics. Results Fifty six per cent of the women were in second trimester. Abortion complications were distributed as follows: 53 % incomplete abortions, 28 % threatened abortions, 12 % inevitable abortions, 4 % missed abortions and 3 % septic abortions. Only one of 238 cases met all criteria of optimal clinical assessment and management. Thus, vital signs were measured in 3 %, antibiotic criteria was met in 59 % of the cases, intravenous fluid resuscitation was administered to 35 % of women with hypotension and pain was managed in 87 % of the cases. Sharp curettage was used in 69 % of those surgically evacuated and manual vacuum aspiration in 14 %. In total 3 % of the abortions were categorized as unsafe. Two of eight women with septic abortion had evacuation performed during admission-day, one woman died due to septic abortion and one from severe haemorrhage. Conclusions Guidelines were not followed and suboptimal assessment or management was observed in all but one case. This was especially due to missing documentation of vital signs necessary to diagnose life-threatening complications, poor fluid resuscitation at signs of shock, and delayed evacuation of septic abortion.
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Affiliation(s)
- Natja Mellerup
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark.
| | - Bjarke L Sørensen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark. .,Centre for Innovative Medical Technology, University of Southern Denmark, Odense, Denmark.
| | - Gideon K Kuriigamba
- Department of Surgery, Makerere University college of Health sciences, Kampala, Uganda.
| | - Martin Rudnicki
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark.
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Mohamed SF, Izugbara C, Moore AM, Mutua M, Kimani-Murage EW, Ziraba AK, Bankole A, Singh SD, Egesa C. The estimated incidence of induced abortion in Kenya: a cross-sectional study. BMC Pregnancy Childbirth 2015; 15:185. [PMID: 26294220 PMCID: PMC4546129 DOI: 10.1186/s12884-015-0621-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 08/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The recently promulgated 2010 constitution of Kenya permits abortion when the life or health of the woman is in danger. Yet broad uncertainty remains about the interpretation of the law. Unsafe abortion remains a leading cause of maternal morbidity and mortality in Kenya. The current study aimed to determine the incidence of induced abortion in Kenya in 2012. METHODS The incidence of induced abortion in Kenya in 2012 was estimated using the Abortion Incidence Complications Methodology (AICM) along with the Prospective Morbidity Survey (PMS). Data were collected through three surveys, (i) Health Facilities Survey (HFS), (ii) Prospective Morbidity Survey (PMS), and (iii) Health Professionals Survey (HPS). A total of 328 facilities participated in the HFS, 326 participated in the PMS, and 124 key informants participated in the HPS. Abortion numbers, rates, ratios and unintended pregnancy rates were calculated for Kenya as a whole and for five geographical regions. RESULTS In 2012, an estimated 464,000 induced abortions occurred in Kenya. This translates into an abortion rate of 48 per 1,000 women aged 15-49, and an abortion ratio of 30 per 100 live births. About 120,000 women received care for complications of induced abortion in health facilities. About half (49%) of all pregnancies in Kenya were unintended and 41% of unintended pregnancies ended in an abortion. CONCLUSION This study provides the first nationally-representative estimates of the incidence of induced abortion in Kenya. An urgent need exists for improving facilities' capacity to provide safe abortion care to the fullest extent of the law. All efforts should be made to address underlying factors to reduce risk of unsafe abortion.
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Affiliation(s)
- Shukri F Mohamed
- Research Division African Population and Health Research Center (APHRC), APHRC Campus, Manga close off Kirawa road, Kitisuru, P.O. Box, 10787-00100, Nairobi, Kenya.
| | - Chimaraoke Izugbara
- Research Division African Population and Health Research Center (APHRC), APHRC Campus, Manga close off Kirawa road, Kitisuru, P.O. Box, 10787-00100, Nairobi, Kenya.
| | - Ann M Moore
- Research Division, Guttmacher Institute, 125 Maiden Lane, 7th floor, New York, NY, 10038, USA.
| | - Michael Mutua
- Research Division African Population and Health Research Center (APHRC), APHRC Campus, Manga close off Kirawa road, Kitisuru, P.O. Box, 10787-00100, Nairobi, Kenya.
| | - Elizabeth W Kimani-Murage
- Research Division African Population and Health Research Center (APHRC), APHRC Campus, Manga close off Kirawa road, Kitisuru, P.O. Box, 10787-00100, Nairobi, Kenya.
| | - Abdhalah K Ziraba
- Research Division African Population and Health Research Center (APHRC), APHRC Campus, Manga close off Kirawa road, Kitisuru, P.O. Box, 10787-00100, Nairobi, Kenya.
| | - Akinrinola Bankole
- Research Division, Guttmacher Institute, 125 Maiden Lane, 7th floor, New York, NY, 10038, USA.
| | - Susheela D Singh
- Research Division, Guttmacher Institute, 125 Maiden Lane, 7th floor, New York, NY, 10038, USA.
| | - Caroline Egesa
- Research Division African Population and Health Research Center (APHRC), APHRC Campus, Manga close off Kirawa road, Kitisuru, P.O. Box, 10787-00100, Nairobi, Kenya.
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Izugbara CO, Egesa C, Okelo R. 'High profile health facilities can add to your trouble': Women, stigma and un/safe abortion in Kenya. Soc Sci Med 2015; 141:9-18. [PMID: 26233296 DOI: 10.1016/j.socscimed.2015.07.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 07/18/2015] [Accepted: 07/20/2015] [Indexed: 11/25/2022]
Abstract
Public health discourses on safe abortion assume the term to be unambiguous. However, qualitative evidence elicited from Kenyan women treated for complications of unsafe abortion contrasted sharply with public health views of abortion safety. For these women, safe abortion implied pregnancy termination procedures and services that concealed their abortions, shielded them from the law, were cheap and identified through dependable social networks. Participants contested the notion that poor quality abortion procedures and providers are inherently dangerous, asserting them as key to women's preservation of a good self, management of stigma, and protection of their reputation, respect, social relationships, and livelihoods. Greater public health attention to the social dimensions of abortion safety is urgent.
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Affiliation(s)
| | - Carolyne Egesa
- African Population and Health Research Center, Nairobi, Kenya
| | - Rispah Okelo
- African Population and Health Research Center, Nairobi, Kenya
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Induced second trimester abortion and associated factors in Amhara region referral hospitals. BIOMED RESEARCH INTERNATIONAL 2015; 2015:256534. [PMID: 25918704 PMCID: PMC4396136 DOI: 10.1155/2015/256534] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/09/2015] [Accepted: 03/16/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND Although the vast majority of abortions are performed in the first trimester, still 10-15% of terminations of pregnancies have taken place in the second trimester period globally. As compared to first trimester, second trimester abortions are disproportionately contribute for maternal morbidity and mortality especially in low-resource countries where access to safe second trimester abortion is limited. The main aim of this study was to assess the prevalence and associated factors of induced second trimester abortion in Amhara region referral hospitals, northwest Ethiopia. METHODS Institution based cross-sectional study was conducted in Amhara region referral hospitals among 416 women who sought abortion services. Participants were selected using systematic sampling technique. Data were collected using pretested structured questionnaire through interviewing. After the data were entered and analyzed; variables which have P value < 0.2 in bivariate analysis, not colinear, were entered into multiple logistic regressions to see the net effect with 95% CI and P value < 0.05. RESULTS The prevalence of induced second trimester abortion was 19.2%. Being rural (AOR = 1.86 [95% CI = 1.11-3.14]), having irregular menstrual cycle (AOR = 1.76 [95% CI = 1.03-2.98]), not recognizing their pregnancy at early time (AOR = 2.05 [95% CI = 1.21-3.48]), and having logistics related problems (AOR = 2.37 [95% CI = 1.02-5.53]) were found to have statistically significant association with induced second trimester abortion. CONCLUSION Induced second trimester abortion is high despite the availability of first trimester abortion services. Therefore, increase accessibility and availability of safe second trimester abortion services below referral level, counseling and logistical support are helpful to minimize late abortions.
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Ziraba AK, Izugbara C, Levandowski BA, Gebreselassie H, Mutua M, Mohamed SF, Egesa C, Kimani-Murage EW. Unsafe abortion in Kenya: a cross-sectional study of abortion complication severity and associated factors. BMC Pregnancy Childbirth 2015; 15:34. [PMID: 25884662 PMCID: PMC4338617 DOI: 10.1186/s12884-015-0459-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 01/29/2015] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Complications due to unsafe abortion cause high maternal morbidity and mortality, especially in developing countries. This study describes post-abortion complication severity and associated factors in Kenya. METHODS A nationally representative sample of 326 health facilities was included in the survey. All regional and national referral hospitals and a random sample of lower level facilities were selected. Data were collected from 2,625 women presenting with abortion complications. A complication severity indicator was developed as the main outcome variable for this paper and described by women's socio-demographic characteristics and other variables. Ordered logistic regression models were used for multivariable analyses. RESULTS Over three quarters of abortions clients presented with moderate or severe complications. About 65% of abortion complications were managed by manual or electronic vacuum aspiration, 8% by dilation and curettage, 8% misoprostol and 19% by forceps and fingers. The odds of having moderate or severe complications for mistimed pregnancies were 43% higher than for wanted pregnancies (OR, 1.43; CI 1.01-2.03). For those who never wanted any more children the odds for having a severe complication was 2 times (CI 1.36-3.01) higher compared to those who wanted the pregnancy then. Women who reported inducing the abortion had 2.4 times higher odds of having a severe complication compared to those who reported that it was spontaneous (OR, 2.39; CI 1.72-3.34). Women who had a delay of more than 6 hours to get to a health facility had at least 2 times higher odds of having a moderate/severe complication compared to those who sought care within 6 hours from onset of complications. A delay of 7-48 hours was associated with OR, 2.12 (CI 1.42-3.17); a delay of 3-7 days OR, 2.01 (CI 1.34-2.99) and a delay of more than 7 days, OR 2.35 (CI 1.45-3.79). CONCLUSIONS Moderate and severe post-abortion complications are common in Kenya and a sizeable proportion of these are not properly managed. Factors such as delay in seeking care, interference with pregnancy, and unwanted pregnancies are important determinants of complication severity and fortunately these are amenable to targeted interventions.
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Affiliation(s)
- Abdhalah Kasiira Ziraba
- African Population and Health Research Center (APHRC), APHRC Campus, Manga Close, off Kirawa road, Kitisuru, P.O. Box 10787-00100, Nairobi, Kenya.
| | - Chimaraoke Izugbara
- African Population and Health Research Center (APHRC), APHRC Campus, Manga Close, off Kirawa road, Kitisuru, P.O. Box 10787-00100, Nairobi, Kenya.
| | | | | | - Michael Mutua
- African Population and Health Research Center (APHRC), APHRC Campus, Manga Close, off Kirawa road, Kitisuru, P.O. Box 10787-00100, Nairobi, Kenya.
| | - Shukri F Mohamed
- African Population and Health Research Center (APHRC), APHRC Campus, Manga Close, off Kirawa road, Kitisuru, P.O. Box 10787-00100, Nairobi, Kenya.
| | - Caroline Egesa
- African Population and Health Research Center (APHRC), APHRC Campus, Manga Close, off Kirawa road, Kitisuru, P.O. Box 10787-00100, Nairobi, Kenya.
| | - Elizabeth W Kimani-Murage
- African Population and Health Research Center (APHRC), APHRC Campus, Manga Close, off Kirawa road, Kitisuru, P.O. Box 10787-00100, Nairobi, Kenya.
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Fotso JC, Izugbara C, Saliku T, Ochako R. Unintended pregnancy and subsequent use of modern contraceptive among slum and non-slum women in Nairobi, Kenya. BMC Pregnancy Childbirth 2014; 14:224. [PMID: 25012817 PMCID: PMC4096734 DOI: 10.1186/1471-2393-14-224] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 07/03/2014] [Indexed: 11/24/2022] Open
Abstract
Background In spite of major gains in contraceptive prevalence over the last few decades, many women in most parts of the developing world who would like to delay or avoid pregnancy do not use any method of contraception. This paper seeks to: a) examine whether experiencing an unintended pregnancy is associated with future use of contraception controlling for a number factors including poverty at the household and community levels; and b) investigate the mechanisms through which experiencing an unintended pregnancy leads to uptake of contraception. Methods Quantitative and qualitative data from a cross-sectional research project conducted in 2009/10 in two slum settlements and two non-slum settings of Nairobi, Kenya are used. The quantitative component of the project was based on a random sample of 1,259 women aged 15–49 years. Logistic regression models were used to assess the effect of unintended pregnancy on future contraceptive use. The qualitative component of the project successfully interviewed a total of 80 women randomly selected from survey participants who had reported having at least one unintended pregnancy. Results Women whose last pregnancy was unintended were more likely to be using a modern method of contraception, compared to their peers whose last pregnancy was intended, especially among the wealthier group as shown in the interaction model. Among poor women, unintended pregnancy was not associated with subsequent use of contraception. The qualitative investigation with women who had an unplanned pregnancy reveals that experiencing an unintended pregnancy seems to have served as a “wake-up call”, resulting in greater attention to personal risks, including increased interest in pregnancy prevention. For some women, unintended pregnancy was a consequence of strong opposition by their partners to family planning, while others reported they started using contraceptives following their unintended pregnancy, but discontinued after experiencing side effects. Conclusion This study provides quantitative and qualitative evidence that women who have had an unintended pregnancy are “ready for change”. Family planning programs may use the contacts with antenatal, delivery and post-delivery care system as an opportunity to identify women whose pregnancy is unplanned, and target them with information and services.
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Affiliation(s)
- Jean Christophe Fotso
- International Consultant, Population & Reproductive Health, Nairobi, Kenya; and Concern Worldwide US, New York, USA.
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Gómez Mercado CA, Montoya Velez LP. Factores sociales, demográficos, familiares y económicos relacionados con el embarazo en adolescentes, área urbana, Briceño, 2012. Rev Salud Publica (Bogota) 2014. [DOI: 10.15446/rsap.v16n3.34986] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Henderson JT, Puri M, Blum M, Harper CC, Rana A, Gurung G, Pradhan N, Regmi K, Malla K, Sharma S, Grossman D, Bajracharya L, Satyal I, Acharya S, Lamichhane P, Darney PD. Effects of abortion legalization in Nepal, 2001-2010. PLoS One 2013; 8:e64775. [PMID: 23741391 PMCID: PMC3669364 DOI: 10.1371/journal.pone.0064775] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 04/11/2013] [Indexed: 11/18/2022] Open
Abstract
Background Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality from unsafe abortion. We sought to assess whether legalization led to reductions in the most serious maternal health consequences of unsafe abortion. Methods We conducted retrospective medical chart review of all gynecological cases presenting at four large public referral hospitals in Nepal. For the years 2001–2010, all cases of spontaneous and induced abortion complications were identified, abstracted, and coded to classify cases of serious infection, injury, and systemic complications. We used segmented Poisson and ordinary logistic regression to test for trend and risks of serious complications for three time periods: before implementation (2001–2003), early implementation (2004–2006), and later implementation (2007–2010). Results 23,493 cases of abortion complications were identified. A significant downward trend in the proportion of serious infection, injury, and systemic complications was observed for the later implementation period, along with a decline in the risk of serious complications (OR 0.7, 95% CI 0.64, 0.85). Reductions in sepsis occurred sooner, during early implementation (OR 0.6, 95% CI 0.47, 0.75). Conclusion Over the study period, health care use and the population of reproductive aged women increased. Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity. The liberalization of abortion policy in Nepal has benefited women’s health, and likely contributes to falling maternal mortality in the country. The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal.
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Affiliation(s)
- Jillian T Henderson
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California San Francisco, San Francisco, California, United States of America.
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Quantifying the global burden of morbidity due to unsafe abortion: Magnitude in hospital-based studies and methodological issues. Int J Gynaecol Obstet 2012; 118 Suppl 2:S65-77. [DOI: 10.1016/s0020-7292(12)60003-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Andersen K, Ganatra B, Stucke S, Basnett I, Karki YB, Thapa K. A prospective study of complications from comprehensive abortion care services in Nepal. BMC Public Health 2012; 12:9. [PMID: 22221895 PMCID: PMC3315730 DOI: 10.1186/1471-2458-12-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 01/05/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In March 2002, Nepal's Parliament approved legislation to permit abortion on request up to 12 weeks of pregnancy. Between 2004 and 2007, 176 comprehensive abortion care (CAC) service sites were established in Nepal, leading to a rise in safe, legal abortions. Though monitoring systems have been developed, reporting of complications has not always been complete or accurate. The purpose of this study was to report the frequency and type of abortion complications arising from CAC procedures in different types of facilities in Nepal. METHODS A total of 7,386 CAC clients from a sample of facilities across Nepal were enrolled over a three-month period in 2008. Data collection included an initial health questionnaire at the time of abortion care and a follow-up questionnaire assessing complications, administered two weeks after the abortion procedure. A total of 7,007 women (95%) were successfully followed up. Complication rates were assessed overall and by facility type. Multivariable logistic regression was used to assess the association between experiencing a complication and client demographic and facility characteristics. RESULTS Among the 7,007 clients who were successfully followed, only 1.87% (n = 131) experienced signs and symptoms of complications at the two-week follow up, the most common being retained products of conception (1.37%), suspected sepsis (0.39%), offensive discharge (0.51%) and moderate bleeding (0.26%). Women receiving care at non-governmental organization (NGO) facilities were less likely to experience complications than women at government facilities, adjusting for individual and facility characteristics (AOR = 0.18; 95% CI: 0.08-0.40). Compared to women receiving CAC at 4-5 weeks gestation, women at 10-12 weeks gestation were more likely to experience complications, adjusting for individual and facility characteristics (AOR = 4.21; 95% CI: 1.38-12.82). CONCLUSIONS The abortion complication rate in Nepali CAC facilities is low and similar to other settings; however, significant differences in complication rates were observed by facility type and gestational age. Interventions such as supportive supervision to improve providers' uterine evacuation skills and investment in equipment for infection control may lower complication rates in government facilities. In addition, there should be increased focus on early pregnancy detection and access to CAC services early in pregnancy in order to prevent complications.
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Adler AJ, Filippi V, Thomas SL, Ronsmans C. Incidence of severe acute maternal morbidity associated with abortion: a systematic review. Trop Med Int Health 2011; 17:177-90. [DOI: 10.1111/j.1365-3156.2011.02896.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Izugbara CO, Ochako R, Izugbara C. Gender scripts and unwanted pregnancy among urban Kenyan women. CULTURE, HEALTH & SEXUALITY 2011; 13:1031-1045. [PMID: 21777108 DOI: 10.1080/13691058.2011.598947] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Women's lived experiences and lay accounts of unwanted pregnancy remain poorly interrogated. We investigated portrayals of unwanted pregnancy using narrative data gathered from 80 women in Nairobi, Kenya. Unwanted pregnancy had a diversity of significance for the women. Pregnancies were not simply unwanted because they occurred when women became pregnant without wanting to. Rather, pregnancies were considered unwanted largely because they had occurred in contexts that did not reinforce socially-sanctioned notions of motherhood and 'proper' procreation and/or revealed women's use of their sexuality in ways deemed culturally-inappropriate. Kenyan women's invocation of femininity scripts to explain unwanted pregnancy; the centrality of gender in everyday life in contemporary Kenya; women's and girls' poor access to effective family planning services; growing female poverty; and Kenya's restrictive abortion policy imply that unwanted pregnancy and its consequences will persist in the country. Addressing unwanted pregnancy and its consequences requires making accessible quality contraceptive and abortion services as well as sexuality information. It also calls for providers who understand the socio-cultural norms that circumscribe fertility and reproductive behaviours.
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Abstract
Forty per cent of the world's women are living in countries with restrictive abortion laws, which prohibit abortion or only allow abortion to protect a woman's life or her physical or mental health. In countries where abortion is restricted, women have to resort to clandestine interventions to have an unwanted pregnancy terminated. As a consequence, high rates of unsafe abortion are seen, such as in Sub-Saharan Africa where unsafe abortion occurs at rates of 18-39 per 1 000 women. The circumstances under which women obtain unsafe abortion vary and depend on traditional methods known and types of providers present. Health professionals are prone to use instrumental procedures to induce the abortion, whereas traditional providers often make a brew of herbs to be drunk in one or more doses. In countries with restrictive abortion laws, high rates of maternal death must be expected, and globally an estimated 66 500 women die every year as a result of unsafe abortions. In addition, a far larger number of women experience short- and long-term health consequences. To address the harmful health consequences of unsafe abortion, a postabortion care model has been developed and implemented with success in many countries where women do not have legal access to abortion. Postabortion care focuses on treatment of incomplete abortion and provision of postabortion contraceptive services. To enhance women's access to postabortion care, focus is increasingly being placed on upgrading midlevel providers to provide emergency treatment as well as implementing misoprostol as a treatment strategy for complications after unsafe abortion.
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Affiliation(s)
- Vibeke Rasch
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark.
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Abstract
Unsafe abortion is a significant cause of death and ill health in women in the developing world. A substantial body of research on these consequences exists, although studies are of variable quality. However, unsafe abortion has a number of other significant consequences that are much less widely recognized. These include the economic consequences, the immediate costs of providing medical care for abortion-related complications, the costs of medical care for longer-term health consequences, lost productivity to the country, the impact on families and the community, and the social consequences that affect women and families. This article will review the scientific evidence on the consequences of unsafe abortion, highlight gaps in the evidence base, suggest areas where future research efforts are needed, and speculate on the future situation regarding consequences and evidence over the next 5-10 years. The information provided is useful and timely given the current heightened interest in the issue of unsafe abortion, growing from the recent focus of national and international agencies on reducing maternal mortality by 75% by 2015 (as one of the Millennium Development Goals established in 2000).
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Ziraba AK, Madise N, Mills S, Kyobutungi C, Ezeh A. Maternal mortality in the informal settlements of Nairobi city: what do we know? Reprod Health 2009; 6:6. [PMID: 19386134 PMCID: PMC2675520 DOI: 10.1186/1742-4755-6-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2007] [Accepted: 04/22/2009] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Current estimates of maternal mortality ratios in Kenya are at least as high as 560 deaths per 100,000 live births. Given the pervasive poverty and lack of quality health services in slum areas, the maternal mortality situation in this setting can only be expected to be worse. With a functioning health care system, most maternal deaths are avoidable if complications are identified early. A major challenge to effective monitoring of maternal mortality in developing countries is the lack of reliable data since vital registration systems are either non-existent or under-utilized. In this paper, we estimated the burden and identified causes of maternal mortality in two slums of Nairobi City, Kenya. METHODS We used data from verbal autopsy interviews conducted on nearly all female deaths aged 15-49 years between January 2003 and December 2005 in two slum communities covered by the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). In describing the distribution of maternal deaths by cause, we examined maternal and late maternal deaths according to the ICD-10 classification. Additionally we used data from a survey of health care facilities that serve residents living in the surveillance areas for 2004-2005 to examine causes of maternal death. RESULTS The maternal mortality ratio for the two Nairobi slums, for the period January 2003 to December 2005, was 706 maternal deaths per 100,000 live births. The major causes of maternal death were: abortion complications, hemorrhage, sepsis, eclampsia, and ruptured uterus. Only 21% of the 29 maternal deaths delivered or aborted with assistance of a health professional. The verbal autopsy tool seems to capture more abortion related deaths compared to health care facility records. Additionally, there were 22 late maternal deaths (maternal deaths between 42 days and one year of pregnancy termination) most of which were due to HIV/AIDS and anemia. CONCLUSION Maternal mortality ratio is high in the slum population of Nairobi City. The Demographic Surveillance System and verbal autopsy tool may provide the much needed data on maternal mortality and its causes in developing countries. There is urgent need to address the burden of unwanted pregnancies and unsafe abortions among the urban poor. There is also need to strengthen access to HIV services alongside maternal health services since HIV/AIDS is becoming a major indirect cause of maternal deaths.
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Affiliation(s)
| | - Nyovani Madise
- University of Southampton, School of Social Sciences, Southampton, SO17 1BJ, UK
| | - Samuel Mills
- World Bank, The World Bank, MSN G7-701, 1818 H Street NW, Washington, DC 20433, USA
| | - Catherine Kyobutungi
- African Population and Health Research Center, P.O. Box 10787, 00100, Nairobi, Kenya
| | - Alex Ezeh
- African Population and Health Research Center, P.O. Box 10787, 00100, Nairobi, Kenya
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Abstract
There will always be women who need abortions after 12 weeks of pregnancy, and their reasons are often compelling. Although second trimester abortions carry relatively more risks than first trimester abortions, abortion is still very safe throughout the second trimester if done in safe conditions. This paper is about law and policy on second trimester abortions, which are allowed on more restrictive grounds than first trimester abortions in most countries, if at all. It focuses on countries where most or at least some second trimester abortions are allowed, including in Europe, where many women are still forced to travel for second trimester abortions, and countries in the developing world, where most second trimester abortions remain unsafe. The need for second trimester abortion should be met in a safe, timely and sympathetic manner. Abortion should be legal at the woman's request up to 24 weeks and on therapeutic grounds after that, and no other barriers or hurdles should be imposed on women seeking second trimester abortion. In-depth, country-based research is needed, to bring out the facts on second trimester abortion, as evidence of why it should be treated as a legitimate form of women's health care and supported in public health policy.
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Gebrehiwot Y, Liabsuetrakul T. Trends of abortion complications in a transition of abortion law revisions in Ethiopia. J Public Health (Oxf) 2008; 31:81-7. [DOI: 10.1093/pubmed/fdn068] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
Unsafe abortions refer to terminations of unintended pregnancies by persons lacking the necessary skills, or in an environment lacking the minimum medical standards, or both. Globally, unsafe abortions account for 67,900 maternal deaths annually (13% of total maternal mortality) and contribute to significant morbidity among women, especially in under-resourced settings. The determinants of unsafe abortion include restrictive abortion legislation, lack of female empowerment, poor social support, inadequate contraceptive services and poor health-service infrastructure. Deaths from unsafe abortion are preventable by addressing the above determinants and by the provision of safe, accessible abortion care. This includes safe medical or surgical methods for termination of pregnancy and management of incomplete abortion by skilled personnel. The service must also include provision of emergency medical or surgical care in women with severe abortion complications. Developing appropriate services at the primary level of care with a functioning referral system and the inclusion of post abortion contraceptive care with counseling are essential facets of abortion care.
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Affiliation(s)
- Susan R Fawcus
- Department of Obstetrics and Gynaecology, University of Cape Town, South Africa.
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Abstract
BACKGROUND Unsafe abortions result not only in costs for acute care but may also be responsible for longer-term complications such as pelvic inflammatory disease, damage to reproductive organs, and secondary infertility. If effective, antibiotic prophylaxis at the time of the procedure can potentially prevent these adverse consequences. OBJECTIVES The value of routine antibiotics before surgical evacuation of the uterus in women with incomplete abortion is controversial. In some health centres antibiotic prophylaxis is advised; in others antibiotics are only prescribed when there are signs of infection. The objective of this review is to evaluate the effectiveness of routine antibiotic prophylaxis to women with incomplete abortion. SEARCH STRATEGY We searched the Cochrane Controlled Trials Register, Pubmed/MEDLINE, EMBASE and Popline. Date of last search: January 2007. SELECTION CRITERIA Randomised trials comparing a policy of routine antibiotic prophylaxis with no routine prophylaxis were eligible for inclusion. DATA COLLECTION AND ANALYSIS Data extraction was conducted by two reviewers independently. Trial quality was assessed. MAIN RESULTS One study involving 140 women was included. A second well-conducted trial was excluded because of high losses to follow-up. No differences were detected in postabortal infection rates with routine prophylaxis or control. However, compliance with antibiotic treatment was also low. AUTHORS' CONCLUSIONS There is not enough evidence to evaluate a policy of routine antibiotic prophylaxis to women with incomplete abortion.
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Affiliation(s)
- W May
- Keck School of Medecine, University of Southern California, USC Division of Medical Education, 1975 Zonal Avenue KAM 218 B, Los Angeles, California 90033, USA.
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Johnston HB, Gallo MF, Benson J. Reducing the costs to health systems of unsafe abortion: a comparison of four strategies. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2007; 33:250-7. [DOI: 10.1783/147118907782101751] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
BACKGROUND Complications from unsafe abortion are believed to account for the largest proportion of hospital admissions for gynaecological services in developing countries. The WHO estimates that one in eight pregnancy-related deaths result from unsafe abortions. The social stigma and legal restrictions associated with abortion in many countries means that data on the magnitude of this problem are scarce; this article estimates the rate and numbers of hospital admissions resulting from unsafe abortions in developing countries to help quantify the problem. METHODS National estimates of abortion-related hospital admissions in women aged 15-44 years were compiled for 13 developing countries: Africa (Egypt, Nigeria, and Uganda), Asia (Bangladesh, Pakistan, and the Philippines), and Latin America and the Caribbean (Brazil, Chile, Colombia, Dominican Republic, Guatemala, Mexico, and Peru). These data were combined with supplementary data from five countries in sub-Saharan Africa (Burkina Faso, Ghana, Kenya, Nigeria, and South Africa) to give estimates for the three world regions. FINDINGS The annual hospitalisation rate varies from a low of about 3 per 1000 women in Bangladesh to a high of about 15 per 1000 in Egypt and Uganda. Nigeria, Pakistan, and the Philippines have rates of 4-7 per 1000, and two countries in Latin America with recent data have rates of almost 9 per 1000. In the developing world as a whole, an estimated five million women are admitted to hospital for treatment of complications from induced abortions each year. This equates to an average rate of 5.7 per 1000 women per year in all developing regions, excluding China. By comparison, in developed countries complications from abortion procedures or hospitalisation are rare. INTERPRETATION These results help quantify the magnitude of the adverse health effects of unsafe abortion in developing countries and highlight the need for improved access to post-abortion care. The provision of abortion services is changing to include the drug misoprostol and this could reduce the severity of abortion complications and the number of women who are hospitalised. Researchers will need to monitor these changes to provide countries with up-to-date information on illness and death from unsafe abortion. Improved contraceptive services are necessary to prevent unintended pregnancy. However, increasing access to safe abortion services is the most effective way of preventing the burden of unsafe abortion, and remains a high priority for developing countries.
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Affiliation(s)
- Susheela Singh
- Guttmacher Institute, 120 Wall Street, New York 10005, USA.
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Abstract
Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19-20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalisation of abortion on request is a necessary but insufficient step toward improving women's health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves women's health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.
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Affiliation(s)
- David A Grimes
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7570, USA.
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Abstract
The evaluation of abortion-care programs and policies has been largely neglected by both national governments and international organizations. This article provides a conceptual framework for evaluating the intermediate outcomes of a safe abortion program, including laws and policies, women's care-seeking behavior, and the quality of, access to, and use of services. The methodological challenges in evaluating these outcomes are described. For each outcome, key indicators for measuring progress in program implementation are offered, along with country examples of successful evaluation approaches. The article concludes with recommendations for improvements in infrastructure, resource availability, and political commitment to support evaluation of safe abortion programs.
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Affiliation(s)
- Janie Benson
- Research and Evaluation, Ipas, 300 Market Street, Suite 200, Chapel Hill, NC 27516, USA.
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Erratum. BJOG 2005. [DOI: 10.1111/j.1471-0528.2005.00759.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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