Abortion: women more at risk of death in fragile and conflict-affected settings

"I was distraught. I had drunk the traditional medicine. Before that, someone had shown me how to insert a piece of iron into my vagina ... It was a piece of iron like this [she shows the interviewer the size]. This person told me it would dilate the cervix, but it didn't work ... She also told me to boil the roots of a plant called Kava with natron [sodium carbonate] and then drink the mixture. After drinking it, I didn't feel well. I felt sick to my stomach and dizzy. My stomach was churning. I couldn't get out of bed. The pains were intense.”

Testimony of a 32-year-old woman admitted to Bangui referral hospital with potentially life-threatening abortion-related complications. 

Around 70% of maternal deaths occur in sub-Saharan Africa (1). Among the five main causes are abortion-related complications - an area in which little progress has been made in recent decades. Yet most abortion-related deaths are the result of unsafe induced abortions (2), which could be largely avoided by providing comprehensive abortion care, including post-abortion care, contraception and safe abortion services.

The AMoCo* study, conducted by Médecins Sans Frontières, Épicentre, Institut Guttmacher and Ipas, in partnership with the Nigerian and Central African Ministries of Health, - and co-funded by MSF and ELRHA/R2HC - shows that severe complications were five to seven times more frequent in the two referral hospitals studied than in African hospitals in the more stable settings studied by the World Health Organisation (WHO) using a similar methodology (3).
 

Severe abortion-related complications include potentially life-threatening complications, near-miss cases and deaths, as defined in the WHO Multi-country Study on Abortion (WHO-MCS-A) using a set of standardised clinical, biological and treatment criteria.

An unsafe induced abortion is carried out by people who do not have the necessary skills to perform it and/or who do not comply with the medical standards in force.

In these two hospitals, more than 50% of women admitted for an abortion-related complication presented with a severe form, mainly haemorrhage (72% in the Nigerian hospital and 58% in the Central African hospital).

The severity of the complications observed can be explained by the inadequacy of post-abortion care services and the many barriers to accessing these services. This is compounded by an increased risk of exposure to sexual violence in these settings, as well as difficulties in accessing contraception. These factors in turn increase the risk of unwanted pregnancy and recourse to unsafe abortion, particularly in places where abortion laws are restrictive.
 

The leading cause of maternal mortality in the Central African Republic

With 829 deaths per 100,000 live births, the Central African Republic has one of the highest maternal mortality rates in the world (4). A study conducted by the Central African Ministry of Health and the United Nations Population Fund (UNFPA) estimated that abortion-related complications accounted for almost one in four maternal deaths (5).

In the Bangui hospital in which the AMoCo study was conducted, admissions for abortion-related complications accounted for 20% of all pregnancy-related admissions during the period studied, which corroborates these results. More than two-thirds occurred during the first trimester of pregnancy. More than a quarter of the women were adolescents aged 18 and under.

"A woman explained to the woman who was accompanying me that if she waited any longer, I might die because I was bleeding out. The motorbike driver also said that he had taken a woman in the same condition to hospital, and that it had saved her life. He told us to hurry and that's how they got me here.”

Testimony of a 35-year-old woman admitted to Bangui referral hospital with near-miss abortion-related complications.

While admissions for abortion-related complications are rarer in the Nigerian hospital than in the Central African hospital (4% of admissions against 20%), more than two-thirds of the women surveyed in Jigawa State presented with a severe complication.

Poor knowledge of safe abortion care options

Around a quarter of the women interviewed in the hospital in Jigawa and 45% of those in Bangui said that they had induced their abortion. More than two-thirds of those surveyed in Bangui and almost all (95%) of those surveyed in Jigawa State had used dangerous methods to induce an abortion, including blunt metal objects or manioc sticks used in septic conditions, injections, traditional herbs and remedies, or medicines.

The risk of very severe complications, including death, was more than three times higher among women who reported an unsafe induced abortion than among other women in the Bangui hospital.

“It's was just a boyfriending thing [but] I got pregnant... I tried to abort myself but it didn't work, so I had to go and see a mother in one of the neighbourhoods... She asked me for 15,000 CFA francs for the abortion, but I only had 13,000 CFA francs, so I gave them to her. She injected me with medicine and she dilated my cervix with a cassava stem and the foetus fell out. Afterwards, I started having abdominal pains."

Testimony of a 27-year-old woman admitted to Bangui referral hospital with near-miss abortion-related complications.

Sources of information about induced abortion were most often informal, usually family members, friends or colleagues. The choice of abortion method seemed to be based more on perceived effectiveness and ease of access than on safety.

When the partner is informed of the pregnancy, he or she is often involved in the decision-making process and choice of abortion method. Spouses who abandon their partners often leave them with no choice but to have an abortion.

“He's preparing his application for military training... It's better to abort this pregnancy if he's not going to be here, he [won't be] comfortable until we've done away with it. At the moment, he has no money to help me with my small business so that I can take care of this pregnancy. How are we going to manage? [He] was the one who went to see [the hospital health worker]. He said he wanted to have an abortion with me because he's not ready at the moment, so he wants us to do the curettage.
[The health worker] agreed.”

Testimony of a 19-year-old woman admitted to Bangui referral hospital with potentially life-threatening abortion-related complications.

“When I spoke to him about the pregnancy, he didn’t reply. One day, I told him that I wasn't feeling well, and he started shouting at me, saying that he wasn't responsible for the pregnancy ... When my partner said this to me, I was confused and wondered what would happen to me if I carried on with the pregnancy. Would I be able to take care of the baby? I couldn't do it on my own, so I bought some medication... [Since then], my partner has run away.” 

Testimony of a 15 year-old girl admitted to Bangui referral hospital with near-miss abortion-related complications.

Difficulties accessing methods of contraception

Difficulties in accessing methods of contraception are also one of the root causes of unwanted pregnancies. Respectively, only 3% of the women surveyed in Jigawa State and 37% of those in Bangui said that they were using some form of contraception at the start of their pregnancy. In Nigeria, the main barriers to the use of modern contraceptives were refusal on the part of the husband and family, the fact that they did not know they could become pregnant and their religious beliefs.
 

In Bangui, fear of the side effects of contraception was the main reason reported. The women also explained that they faced difficulties ensuring the continuity of their contraception, with a lack of available alternative methods, high transport costs and opening hours that made it impossible to buy them.

"I didn't have anyone to go with me, and what's more I didn't have the time. I leave for work at seven in the morning and I get home at 11 o'clock at night. I don't have time to pick up the pill ... I [simply] don't have the time.”

Testimony of a 32-year-old woman admitted to Bangui referral hospital with potentially life-threatening abortion-related complications.

Extremely long delays in accessing care

The AMoCo study also describes women’s long and difficult post-abortion care pathway, exacerbating the complications and the risks they face. Half of them took two days or more after the first symptoms appeared to get to a suitable health facility. 27% of the women surveyed in Nigeria and 16% in the Central African Republic took six days or more. Symptoms are often not perceived as serious at first, let alone as a priority. Some women don't realise that they are pregnant.
 

"I had pain in my lower abdomen and here [she touches her back and hips with her hands], it hurt a lot [...]. At one point, I wondered if it wasn't because of how far I have to walk every day.”

Testimony of a 27-year-old woman admitted to Jigawa State referral hospital with near-miss abortion-related complications.

"The things that happened to me are simply... I was sitting down when all of a sudden the bleeding started. I assumed or thought that I wasn't pregnant. So I didn't worry about it. It was after two days that things got serious;, that's when the bleeding became heavy and persistent.”

Testimony of a 30-year-old woman admitted to Jigawa State referral hospital with near-miss abortion-related complications.

In other cases, women simply want to keep their abortion secret.

"I had often heard that after the curettage, you felt better... I thought that one day or other the foetus would come out and I'd feel better... I couldn't swallow anything. I couldn't get out of bed... I was in pain day and night. I took the medication that [the abortionist] gave me, but it wasn't any good... As things got more complicated, I got scared, because my family wouldn't have agreed to me having an abortion. I didn't tell anyone about my situation, I became very withdrawn and shut myself away at home."
Testimony of a 21-year-old woman admitted to Bangui referral hospital with near-miss abortion-related complications.

When the symptoms get worse, they often decide to return to the person who performed the abortion or to untrained care providers, which further increases delays in seeking care and accessing adequate treatment. Women initially try to manage the symptoms at home with medicines they have bought themselves (including pharmaceuticals and traditional treatments).

Delays in accessing care are compounded by a lack of information about appropriate health facilities to care for the women. They must also find the money to pay for transport and cover the costs of treatment, as well as someone to accompany them. For example, most of the women who took part in the study didn’t know that services at Bangui hospital were provided free of charge.

"If there had been a means of transport, a safe way of getting patients to hospital, it would [have] helped me... There should be ambulances for health facilities like the maternity hospital... To take me to Castors, there was no ambulance, so the person accompanying me had to go to the main road to look for a motorbike... With no transport and the insecurity in the area, I had to wait until daylight to leave my house... The worst thing was that it was the weekend, a Sunday, and on that day it's hard to find any transport; the taxis don't really work on Sundays. I lost a lot of blood that day and nearly died."
Testimony of a 35-year-old woman admitted to Bangui referral hospital with near-miss abortion-related complications.

"You see, it's not like our house is by the side of the road. And there was no way I could sit on a motorbike. So, they had to use a cart to carry me to a car."

Testimony of a 32-year-old woman admitted to Jigawa State referral hospital with potentially life-threatening abortion-related complications.

Aggravating factors in Nigeria

While admissions for abortion-related complications are rarer in the Nigerian hospital than in the Central African hospital (4% of admissions against 20%), more than two-thirds of the women surveyed in Jigawa State presented with a severe complication.

Chronic anaemia among women in this very poor rural region probably worsens the complication. This could go some way towards explaining the higher proportion of women with severe complications. 67% of women with no significant bleeding had anaemia (compared with 38% in the Central African Republic), suggesting that they probably had underlying chronic anaemia. National surveys have confirmed this data, showing that the proportion of women of childbearing age with anaemia in Jigawa State is one of the highest in the country (5).

In addition, 61% of abortion-related complications occurred during the second trimester, i.e. later than in the Bangui hospital, which may also explain why they were more severe.

Unsafe abortion remains one of the leading causes of maternal mortality in the world, and the only one that is almost entirely preventable.

“In fragile or conflict-affected settings, as elsewhere, in order to save the lives of many women and reduce their suffering, we need to provide access to free contraceptive services offering a wide range of methods, both in primary health centres and in hospitals," explains Dr Estelle Pasquier, a medical researcher at Epicentre and co-leader of the AMoCo study. “We need to invest in improving communities' knowledge of safe contraceptive and abortion methods, and make post-abortion care and safe abortion care easily accessible, including at primary healthcare level.”

Illustrations : Alice Wietzel

* AMoCo : Abortion-related Morbidity and mortality in fragile and Conflict-affected settings. Conducted in collaboration with the Central African Republic and Nigerian Ministries of Health, the AMoCo study gathers data from 1,068 women presenting with abortion-related complications.

1. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division https://www.who.int/publications/i/item/9789240068759

2. Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, et al. Unsafe abortion: the preventable pandemic. Lancet [Internet]. 2006 Nov 25 [cited 2020 Jul 13];368(October):1908–19. Available from: https://pubmed.ncbi.nlm.nih.gov/17126724/

3. Qureshi, Zahida & Mehrtash, Hedieh & Kouanda, Seni & Griffin, Sally & Filippi, Veronique & Govule, Philip & Thwin, Soe Soe & Bello, Folasade & Gadama, Luis & Msusa, Ausbert & Nafiou, Idi & Goufodji, Sourou & Kim, Caron & Wolomby-Molondo, Jean-Jose & Mugerwa, Kidza & Bique, Cassimo & Adanu, Richard & Fawole, Bukola & Madjadoum, Thierry & Tunçalp, Özge. (2021). Understanding abortion-related complications in health facilities: Results from WHO multicountry survey on abortion (MCS-A) across 11 sub-Saharan African countries. BMJ Global Health. 6. e003702. 10.1136/bmjgh-2020-003702.

4. WHO, UNICEF, UNFPA, World Bank, UNDP. Trends in maternal mortality 2000 to 2017. [Internet]. Geneva: World Health Organisation; 2019.

5. Ministère de la santé de la République Centrafricaine, UNFPA. Évaluation de la disponibilité, de l’utilisation et de la qualité des soins obstétricaux d’urgence dans la zone d’intervention de l’UNFPA en République Centrafricaine. Bangui; 2010.

6. National Population Commission (NPC) [Nigeria], ICF. Nigeria Demo‑ graphic Health Survey 2018. 2019. p. 748. https://dhsprogram.com/publi cations/publication-fr359-dhs-fnal-reports.cfm. Accessed 8 Feb 2023