AMoCo: Severe complications up to seven times more likely in two hospitals in fragile and conflict-affected settings

Wednesday 30 August 2023 - Updated on Tuesday 21 November 2023
The AMoCo study assessed the extent and severity of abortion-related complications and factors associated with serious or near-miss events in two African humanitarian settings

What is AMoCo?

Aborption complications Amoco

This mixed method, cross-sectional study aimed to describe and estimate the burden of all abortion complications and factors associated with severe morbidity among women admitted for postabortion care (PAC) in two referral facilities in Nigeria and Central African Republic (CAR).


Findings showed that women experienced more severe abortion complications compared to results of similar studies in more stable settings.  Potential contributing factors include delays in accessing post-abortion care, low access to contraceptive and safe abortion care, and increased food insecurity leading to iron deficiencies and chronic anaemia. Results highlight the need for greater access to high-quality contraception, safe abortion care and post-abortion care in fragile and conflict-affected settings.




Abortion-related complications are among the five main causes of maternal mortality, and often the result of unsafe abortions, which are largely preventable with quality, accessible post-abortion care, safe abortion care and contraceptive services.

In CAR and Nigeria, both fragile and conflict-affected countries, abortion-related complications are significant contributors to high maternal mortality rates. Limited evidence is available on abortion complications in fragile and conflict-affected settings to identify care needs and priorities to address the challenge in these settings.



A cross-sectional study using prospective medical record reviews and quantitative interviews was conducted with women presenting with abortion-related complications at the two facilities between November 2019 - July 2021. Qualitative interviews with women with severe complications to understand their pathways to care; facilities assessments to understand their capacity to provide post-abortion care; and a knowledge, attitudes, behaviours, and practices survey of facilities’ health professionals were also completed.


Key Findings

  • Over 500 women were included in the study from each hospital setting. In the CAR hospital, abortion complications constituted nearly 19.9% of all pregnancy-related admissions; it was lower in the Nigerian hospital (4.2%).
  • Severity of abortion-related complications was high: over 50% of complications in the CAR hospital and over 65% in the Nigerian hospital were severe.
  • In the Nigerian hospital, 1 in 4 women interviewed reported having tried to induce their abortion. In the CAR hospital, the figure was nearly 1 in 2, many resulting in very severe or life-threatening complications. In both settings, most women had used unsafe methods to induce their abortions.
  • There was diversity in abortion attitudes and gaps in knowledge and practice related to abortion care. A low level of knowledge about WHO-recommended medication abortion regimens was observed.
  • There were a range of delays in care-seeking with many women taking days to reach care after the onset of symptoms. Pathways to care were complex. Barriers to accessing care included difficulties in navigating the health care system and a lack of referral pathways.



High severity of abortion complications in fragile and conflict-affected settings: a cross-sectional study in two referral hospitals in sub-Saharan Africa (AMoCo study).

Journal Reference: BMC pregnancy and childbirth 2023 Mar 04; 23(1); . doi: 10.1186/s12884-023-05427-6. Epub 2023 03 04

Reasons for delay in reaching healthcare with severe abortion-related morbidities: Qualitative results from women in the fragile context of Jigawa State, Nigeria (AMoCo)

Journal Reference: SSM - Qualitative Research in Health. 15 August 2023, 100330.
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Main results on video


What are the implications for humanitarian actors and political decision-makers?

Contraception Amoco Alice Wietzel The need is high for greater access to high quality contraception, safe abortion care, and postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings. Addressing this challenge should be a high priority for donors and public health actors to reduce maternal morbidity and mortality in fragile and conflict-affected settings.

Preventing and managing underlying chronic health conditions like malnutrition and chronic anemia may reduce the lethality of abortion complications.

Attention may be needed to strengthen capacities of health care facilities and staff to provide quality post-abortion, contraceptive and safe abortion care, and to improve pathways to care; recognising the complex social, cultural and legal issues that can constrain policymaking and investments for these care, in particular safe abortion and contraceptive care.



Illustrations: Alice Wietzel

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Référence profils

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