Abortion

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 Abortion
Objectives:
At the end of the chapter, the student is expected to:
• Understand the magnitude of abortion
• Identify reasons behind unplanned pregnancy
• Define Unsafe abortion and know contributing factors
• Understand different components of post abortion care
• Know the revised Penal Code of Ethiopia on Safe
abortion

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 Definition
• Abortion is the termination or initiation of
termination of pregnancy before reaching viability
(before 20weeks or <500grams or before 28 weeks
of gestation
• It can be spontaneous where termination is not
provoked deliberately or
• induced abortion when there is a deliberate
interference with the pregnancy for the sake of
terminating it

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 Abortion
• Each year, throughout the world, approximately
210 million women become pregnant &
• over 135 million of them deliver live infants
• It was estimated that, approximately, 42 million
pregnancies were terminated voluntarily :
• 22 million safely &
• 20 million unsafely (2003 )
• The total number of unsafe abortions has increased
from about 20 million in 2003 to 22 million in 2008,

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 Abortion

• Approximately 47 000 pregnancy-related deaths are

due to complications of unsafe abortion
• In addition, 5 million women are estimated to suffer
disability as a result of complications due to unsafe
abortion
• More than 1/3rd of all pregnancies are unintended, & 1
in 5 (20%) ends in abortion

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 Global Trends of abortion

• In developing countries, 2/3rd of unintended

pregnancies occur among women who were not
using any method of contraception ( Singh S, et al)
• The world’s lowest abortion rates are in Europe,
where abortion is legal and widely available but
contraceptive use is high;
• In Belgium, Germany, and the Netherlands, the
rate is below 10/ 1000 women aged 15 to 44
years.

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 Global Trends…
• In contrast, in Africa, Latin America, & the Caribbean,
where abortion laws are the most restrictive and
contraceptive use is lower, the rates range from the
20s to 39 per 1000 women (Sedgh G,et al)
• Data suggest that even as the overall abortion rate has
declined, the proportion of unsafe abortion is on the
rise

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• In Ethiopia it is estimated that 3.27 million
pregnancies occur every year of which approximately
500,000 end in either spontaneous or unsafely
induced abortion
• Unsafe abortion is the commonest cause of maternal
mortality accounting for up to 32% of all maternal
deaths in Ethiopia

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 Unsafe Abortion

Definition:
• WHO defines unsafe abortion as a procedure for
terminating an unintended pregnancy carried
out
• either by persons lacking the necessary skills or
• in an environment that does not conform to
minimal medical standards, or both
• some abortions are self-induced

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 Unsafe Abortion
The risks of unsafe abortion are aggravated by:
• unhygienic conditions,
• dangerous interventions or
• incorrect administration of medication
• Although unsafe abortions are preventable, they
continue to pose undue risks to a woman’s
health and may endanger her life

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 Unsafe Abortion

• Unsafe abortion is among the top five causes of

pregnancy-related death in the developing
world, killing at least 68,000 women per year
• Although unsafe abortion is the most easily
preventable cause of maternal death and
disability, it has not yet been widely integrated
into safe motherhood programmes

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 Unsafe Abortion
• Each year at least 2 million young women worldwide
have unsafe abortions; mainly due to inaccessibility of
safe services or costs
• these unsafe abortions could be a result of:
–Self induced
–Unskilled or non-medical providers
–Delay in seeking abortion (>3 months of pregnancy)
In African,38-68% women seeking hospital care for
abortion are adolescents
• In Africa about 1/4th of the unsafe abortions are among
teenagers (15-19)= higher than any region

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 Unsafe Abortion

• Most abortions are clandestine

• Unmarried young women are more likely to resort to
clandestine abortions & unskilled providers
• Greater contraceptive access and use alone can thus
drastically reduce safe and unsafe abortion by
reducing unintended pregnancies

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• One in four women who undergo unsafe abortion is likely to
develop temporary or lifelong disability requiring medical care
(22).
• For every woman seeking post-abortion care at a hospital, there
are several who have had an unsafe abortion but who do not
seek medical care, because :
• they consider the complication as not serious, or
• they may not have the required financial means, or
• they fear abuse, ill-treatment or legal reprisal

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• The burdens of unsafe abortion and of maternal deaths
due to unsafe abortion are disproportionately higher for
women in Africa than in any other developing region
(31).
• For example, while Africa accounts for 27% of global
births annually,
• But its share of global unsafe abortions was 29% and,
• more seriously, 62% of all deaths related to unsafe
abortion occurred in Africa (2008)

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 Unsafe Abortion

• Methods of unsafe abortion include drinking

toxic fluids;
• inflicting direct injury to the vagina, cervix,
or rectum; or
• inflicting external injury to the abdomen
• Complications also arise from unskilled
providers causing uterine perforation and
infection

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 Unsafe Abortion

• Data indicate an association between unsafe abortion

and restrictive abortion laws
• Preventing unintended pregnancy, providing better
access to health care, &
• liberalizing abortion laws to allow services to be openly
provided can reduce the rate of abortion-related
morbidity and mortality
• However, sociopolitical and religious obstacles have and
will continue to play a role in passing abortion laws

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 Unsafe Abortion

Reasons for unsafe abortion

Mistimed pregnancy
Fear of being expelled from school
Anxiety about having a child out of marriage
Financial problems to care for the child
Uncertainty regarding their partner’s attitude&
acceptance of the pregnancy

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 Methods of estimating incidence of unsafe
abortion
• Where induced abortion is restricted and largely inaccessible,
or little information is available on abortion practice, it is
difficult to quantify & classify abortion
• The occurrence of unsafe abortion tends to be underreported in
surveys ; only hospital records are reportable
• Only the “tip of the iceberg” is, therefore, visible in the
number of deaths and the number of women who seek medical
care following complications

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 Methods of estimating…
• Information relevant to understanding & measuring unsafe
abortion covers data from:
• hospital records and surveys,
• research on abortion providers,
• abortion-seeking behavior, &
• post abortion care

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 Methods of estimating…

• percentages of unsafe abortion-related deaths as a cause of

maternal mortality are generated first by country, and then
aggregated by sub region, regions and then globally
• Absolute numbers of unsafe abortions cannot be compared
meaningfully across different regions and sub regions because
of differing population size
• Ratios (relative to live births) and rates (relative to women of
reproductive age of 15–44 years) are therefore calculated for
comparisons

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 Methods of estimating…
• In summary, the incidence indicators for sub regions, regions
and globally, are calculated for two differing groups of
countries:
• (1) for all countries of a sub-region; and
• (2) for the countries of that sub region with evidence of
unsafe abortion, thereby excluding from the denominator the
populations of countries where there is no evidence of unsafe
abortion
• These countries do not contribute to the incidence of unsafe
abortion and therefore are excluded from the denominator for
calculating rates or ratios

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 Consequences of unsafe abortion

The health consequences of unsafe abortion depend on:

• the facilities where abortion is performed;

• The skills of the abortion provider;
• the method of abortion used;
• the underlying health conditions of the woman; and
• the gestational age of her pregnancy at abortion

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• One in four women who undergo unsafe abortion is
likely to develop temporary or lifelong disability
requiring medical care (Singh S. 2006)
• For every woman seeking post-abortion care at a
hospital, there are several who have had an unsafe
abortion but who do not seek medical care,
• b/c they consider the complication as not serious, or
they may not have the required financial means, or
b/c they fear abuse, ill-treatment or legal reprisal
(Juarez F et al2005)
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 Consequences of unsafe abortion
Besides death, possible complications include:
1. Immediate health problems:
• Sepsis, hemorrhage, cervical laceration, uterine perforation,
toxic reaction to drugs used
2. Long-term health problems such as:
• chronic pain, pelvic inflammatory disease, infertility and
Ectopic pregnancy

These problems can result in:

• lowered productivity
• inability to care for children,
• adverse effect on sexual relations

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Causes of Maternal Death in Ethiopia

Others Haemorrhage
15% 10%
Sepsis
12%

Hypertention
Abortion 9%
32%
Obstructed
labor
22%

Facility based, Ethiopia

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 Consequences of…

Unsafe abortion also places a substantial burden on health care

systems
• women with incomplete abortion account for half of
gynaecological admissions at hospitals, and
• treatment may required several days of hospitalization, &
• significant staff time, blood transfusion, and anaesthesia

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 Why Unwanted Pregnancy?

1.Non-use of contraception
• The majority of unwanted pregnancies occur in Nonusers of
contraceptive methods.
2. Contraceptive failure
• Contraceptive failure results in 8-30 million pregnancies each
year either:
• from inconsistent or
• incorrect use of FP methods or
• method-related failure

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3. Sexual coercion or rape
• 20-50% of women & girls report sexual abuse, rape or sexual
coercion
• which carries about 5% risk of pregnancy in those
reproductive age unless emergency contraceptives is used
4. Other factors
• Younger age
• unstable relationship
• Mental or physical health problems
• poverty
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5.Inadequate services
• In many developing countries, safe abortion services are not
available to the full extent permitted by law
• Lack of protocols for post-abortion care,
• Many health workers lack vital information about the legal
status of abortion,
• Negative attitudes on the part of health care providers

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 Legislation and policies

When abortion is illegal,

• It is most difficult for a woman to obtain it,
• Society is generally against abortion, and
• The psychological trauma is generally great
Evidence shows that restrictive legislation is associated with
higher rates of unsafe abortion and correspondingly high
mortality.

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 Why is the risk so high in Africa?
• Emergency services are not accessible
• Few paramedical staff are trained in PAC
• Patients arrive in late and in poor condition
• D&C is the primary clinical management
– Delay of action in hospitals: waiting for OT & staff add
risk of complications
• Community understanding is poor and cultural barriers are a
reality

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Post abortion care

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 Post abortion care

• Post abortion care (PAC) is a strategy for reducing

mortality and morbidity
• resulting from complications of incomplete and
unsafe abortions
• PAC includes both treatment of abortion
complications and provision of post abortion family
planning
• to prevent future unwanted pregnancies,
• as well as other counseling and services that women
may need

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Elements of post abortion care

Emergency FP Counseling
Treatment & Services

Linkage with Other

Reproductive
Health Services

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 Elements of post abortion care
But practically, there are five essential elements, which are:
1.Community-service provider partnerships
• involving the local community and informal health workers
(CHAs, CBRHAs, TBAs)
• These partnerships are designed to increase recognition of
the signs and symptoms of pregnancy complications,
• to mobilize resources, and
• to address social and economic issues at the community
level.
2. Counseling, on RH issues including FP, voluntary
counseling and testing (VCT), and gender-based violence
(GBV)

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 Elements of post abortion care
3. Emergency treatment of incomplete abortion and its
complications.
4. FP services based on free and informed choice and
the availability of methods.
5. Linkage of the above services with other
reproductive health services including the diagnosis
and treatment of sexually transmitted diseases
(STDs);
• Information on breast feeding, child nutrition, and
immunization;
• Screening of reproductive tract cancers; and so on.

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 Emergency Treatment

• Post abortion care is the management of a medical emergency

• It is care for women with complications of abortion
• The aim is to improve the quality and expand the services
availability
• Many hospitals manage patients with complications of
abortions, but . . .
• Quality, accessible PAC services are currently limited to only
few hospitals

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 Emergency Treatment

Using Manual Vacuum Aspiration (MVA)

MVA is the preferred treatment of incomplete abortion because:
 Risk of complications is reduced
 Access to services is increased
 Cost of post abortion services & consumption/ use of
resources is reduced
 Immediate access to emergency care is much more likely

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 FP Counseling services

• Preventive services (i.e. family planning counseling &

services)
FP is a preventive service for PAC clients
Increased risk of repeat pregnancy:
– Ovulation may occur by day 11 post abortion
– 75% of women will have ovulated within 6 weeks post
abortion

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 FP Counseling services
FP Methods for PAC
• Oral Contraceptive Pills
• Injectables
• Condoms
• Intrauterine Devices (After uterine involution)
• Implants
• Female Sterilization / Vasectomy
• Training staff in FP counseling & method provision
• Ensuring that FP counseling & methods are always
available, in the emergency care setting
• Establishing clear protocols for FP follow-up after initial
supply (e.g., an effective referral system to a FP clinic)
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 Linkage with Other RH services
• Existing services aimed at emergency care only
• Little effort made to prevent future abortions through IEC or
advocacy
• HIV counseling, referral for VCT
• Treatment of sexually transmitted diseases (STDs)
• Cervical cancer screening for women over age 30-35
• Pre-pregnancy advice (e.g., nutrition, immunization,
management of existing medical conditions)
– Positive, non-judgmental staff attitudes
– Psychosocial support and counseling
– Proper pain management

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 summary
• Preventing unintended pregnancy should be a priority
• Educating women regarding their reproductive health
should be incorporated in schools
• Increasing quality contraceptive services
• providing accurate information, choices and proper
use of contraceptive methods ( like EC)
• Governments &NGOs need to find effective ways to
overcome cultural and social misconceptions that
restrict women from receiving necessary health care

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 Summary
• In order to prevent unsafe abortion: reproductive health
programmes must strive to prevent unwanted pregnancies by
reaching more clients and
• offering them high-quality services.
• Even a perfect family planning programme, however, cannot
eliminate the need for safe abortion services

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 summary
• PAC is a life saving service
• Quality PAC Services require:
– Prompt and safe emergency treatment
• with MVA, for most cases
– Positive, non-judgmental staff attitudes
– Psychosocial support and counseling
– Proper pain management
– Preventive services (i.e. family planning counseling &
services)
– Linkages to other RH services

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Thank you

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