Management of unsafe abortion in Africa

 

By Oluwasola Samuel, Freelance Writer.

Medical reviewer: Dr. Azuka Ezeike, MBBS, FWACS (Obstetrics and Gynaecology), MSc (Public Health),

 

It's important to note that unsafe abortion can lead to life-threatening complications. As a result, post-abortion care is crucial to preserving and managing complications.

 

If you or anyone you know is experiencing complications, here are some management options that your professional healthcare provider would offer:

 

1. Immediate care 
 

• Initial Assessment: A healthcare provider who is not a specialist gynaecologist (women’s reproductive health doctor) may do this. The assessment will involve taking a detailed history from you, followed by a full clinical examination. The provider will also request some laboratory and diagnostic tests (e.g., complete blood count, chemistry profile including electrolytes and blood urea, urine check, pelvic ultrasound scan, etc.)  

 

At the end of or even during the initial assessment, and depending on the severity of your case, the first line healthcare provider may place you on intravenous fluid replacement medications through a delivery system that is made up of a needle at the end of a tube, and then ask for a gynaecologist to take over your care.
 

• Blood Replacement: If you have lost lots of blood, your gynaecologist will request for compatible blood and/or other blood products to be given to you through the intravenous route. You will be properly monitored for safety during and after blood transfusion.

 

• Pain Management: If your pain is severe, your gynaecologist will give you strong pain medications. This medication will relieve your pain and make you feel better.

 

• Severe bleeding: If the bleeding is heavy, your gynaecologist will examine you to check for the cause. In addition to the blood transfusion, you may be given an oxytocic drug to help the muscles of your uterus contract more and stop bleeding.

 

• Surgery: If your gynaecologist suspects that you have a punctured or perforated uterus, or the abortion is incomplete, you will need immediate surgery to repair the perforation or complete the abortion through removal of any retained products of conception. Doing these will help you to get better. 

 

Surgery can also be required if your bladder or bowel are also damaged.
 

• Antibiotics: If you have heavy bleeding, an infection, or an incomplete abortion, your gynaecologist will administer antibiotics by injection either into your muscles or blood vessel (vein). These medications are powerful and are used to fight infections. If overused, it can result in antibiotic resistance. As a result, your gynaecologist will administer it with due consideration for need and benefits.

 

When antibiotics are needed in the period following immediate post-abortion care, it is often given by mouth.
 

• Sepsis treatment: Sepsis is a severe or life-threatening infection that needs urgent attention. If your gynaecologist suspects you’re in sepsis, they will begin some of the immediate life-threatening  treatments detailed earlier using antibiotics, and as necessary may place you on a ventilator (breathing machine) or dialysis (to help your kidneys work well in case of kidney issues).  

 

• Ultrasound: As you may recall, a pelvic ultrasound scan is a test used in your initial assessment to see if any tissue remains in your womb following abortion. The test may also give indication if your womb is perforated. The imaging device helps your gynaecologist to determine the best line of actions to take in your immediate and post-abortion care.

 

2. Public health care approach

 

Given the several complex causes of unsafe abortion as earlier discussed, and notwithstanding the immediate care that is offered to victims of this condition, it is vital that your healthcare provider also adopts a public health approach to immediate and post abortion care. 

 

This approach shifts the model of care from facility (clinic/hospital) based to a broader public health care of women’s reproductive and sexual health needs. [6]

 

A summary of the components of this approach are discussed under two broad headings:

 

During the immediate care visit

Provide counseling, education and other reproductive health services about prevention of unwanted pregnancies, contraception, proper pregnancy spacing and reduction of unsafe abortions.

 

For long term post-abortion care

Providers should work with other community members who are stakeholders in reducing the occurrence of unsafe abortions in their respective countries, to advocate:
 

• That all women who want to prevent or space pregnancies can obtain contraceptive services at the most affordable cost.

• That all women have access to services to manage complications from abortion whether induced or spontaneous; at a cost that is affordable to them.

• For the education of women about how to seek sexual and reproductive health care generally.

• For the availability of funding support for public ambulance transportation for example such that women can receive early care for obstetric emergencies.

• For special support for vulnerable populations of women in need of sexual and reproductive health care (e.g., adolescents, women with HIV or AIDS, those who have experienced violence or genital cutting, women who have sex with women, refugees, commercial sex workers, and women with mental and physical challenges).

• For a properly planned and implemented broad human rights based approach to sexual and reproductive health policies and services that satisfies the expectations of the respective community served.  

 

Consequences of unsafe abortion 

 

Imagine getting pregnant when you least expected it. Afterwards, you visit your doctor for a safe abortion, but you are turned back due to the restrictive abortion laws in your country. Knowing there is no other option, you go ahead and abort the pregnancy in unsafe circumstances.  

 

This is the reality for many young girls and adult married and unmarried women in Africa. This can have serious health consequences for women and public health generally.

 

Here are some of the consequences that unsafe abortion poses to the individual and public health:

 

1, Infertility and Mental health issues

In an African setting, it's believed that once you are married, you are expected to start giving birth. As infertility is a major complication of unsafe abortion, a woman with infertility is likely to come under the stress of cultural expectations and become restless. This can harm her physically and mentally (depression or anxiety). 

 

Note that mental health challenges can also result directly from the stress and worries of undertaking unsafe abortions.

 

2. Loss of life

The saddest part of unsafe abortion is that it is a leading cause of maternal death in sub-Saharan Africa. This means that the lives of many young girls and women who could have had a bright future are being cut short. 

 

3. Loss of potential

Educational, career and financial opportunities may be lost to women due to unintended and unwanted pregnancy in the first place. Unsafe abortion with its associated complications may compound this loss directly for women and indirectly for society at large due to economic and other opportunity loss.  

 

4. Overburden healthcare services

With many women ending up in hospital emergency rooms as a result of complications from unsafe abortion, more stress is placed on an already weak and overburdened health system resources (facilities and healthcare professionals). This will cause poor systems performance and reduced community satisfaction with erosion of community trust in public health services. 

 

“Many sub-Saharan countries have few medical resources and qualified medical professionals available. This means that there will be fewer medical professionals treating lots of patients. This will limit medical professionals from performing at their optimal best. Dr. Osom Onyeuche explains.

 

5. Lost opportunity for post abortion care protocols

As unsafe abortions are often done in secrecy, opportunities are often lost for a public health-centered approach to immediate and post abortion care as detailed. This is disadvantageous to women individually and to the public in general.

 

But here is the good news; all the public health consequences discussed can be reasonably confronted and reduced with the following action steps:

• Public service provision of information to men and women generally on safe sex and reproductive health practices

• Public sensitisation and assurance on the availability of free or low cost contraceptive services

• Provision of programs in existing or specially created primary care facilities for adolescent health. Such programs should be serviced by trained non-judgemental community health workers and peers

• Inclusion of post abortion care protocols in existing healthcare facilities at all levels (primary, secondary and tertiary)

• Public sensitization and assurance of ready access to free or low-cost contraception to women within the principles of reproductive health rights. 

• Coverage of abortion services in Universal Health Insurance provisions.

• Improvement in primary care facilities and trained personnel in rural and urban centers for women’s health services.

• Multi-stakeholder promotion of health advocacy and education about women reproductive health generally.

• Reorientation of “objecting” health workers to abortion care towards a more public health-centered participation in sexual and reproductive health counseling and education. 

• Reform of unduly restrictive abortion laws that exist in many African countries towards open access to abortion care, as championed by Benin and Sao Tome and Principe (5).

• Provision at public cost of safe homes for young girls with unwanted pregnancies to help shield them from stigma.

 

Most of these proposals, if implemented, will enrich the quality of sexual and reproductive lives of girls and adult women in Africa and save needless deaths

.

Frequently asked questions

 

1. Why do women undergo unsafe abortions?

Women undergo unsafe abortions for many personal reasons. 

Some of the reasons include:

• Restrictive abortion laws

• When pregnancy is unintended and or unwanted

• When pregnancy is a result of rape or incest

• Economic factor

• Shame and stigma in society 

• Cultural and societal reasons

• Desire to continue education

 

2. What's the meaning of an unsafe abortion?

Unsafe abortion is done by someone with little to no clinical experience. It can also be done by someone with clinical expertise, but in an unhygienic environment.

 

“An abortion can also be termed unsafe when the pregnant woman uses over-the-counter drugs without a prescription to abort a pregnancy. This is unsafe because it could cause heavy bleeding. If bleeding is not stopped quickly, it could lead to severe anaemia, shock or death." Dr. Osom Onyeuche says.
 

3. How can unintended or unwanted pregnancy be prevented?

Unintended and /or unwanted pregnancy is one of the leading reasons why many girls and married or unmarried adult women abort their pregnancies. To limit this, there is a need for girls and women who are sexually active to have ready access to low-cost contraception, including emergency contraceptives. They also need to be educated on how to use them correctly.
 

4. What's an incomplete abortion?

Abortion can be induced (medical abortion) or spontaneous (miscarriage). During the process of abortion, your uterus ought to be empty from the contents of your pregnancy. In certain situations, some pregnancy-related tissues remain in your womb (uterus) to produce incomplete abortion. This can cause cramps, bleeding (haemorrhage), or infections that can harm your sexual or reproductive and other body organs.

 

“Incomplete abortion can lead to infection in and around the womb. It can spread through your fallopian tube to cause infertility. It can also spread into your blood (septicaemia) and cause multiple organ failure in your body,” Dr. Osom Onyeuche explains.
 

5. What is the difference between safe abortion and unsafe abortion?

The difference between a safe and unsafe abortion is the “safety” measures put in place during abortion.  

Abortion is safe when:

• It's carried out by expert healthcare professionals (gynaecologists or nurses).

• It's carried out in a clean and well-equipped facility while using sterilised tools to prevent you from getting infected.

• You get clear information and understanding about the procedure, your potential risk, and post-abortion care, in case the need arises.

• You get proper monitoring and medication to help you heal from the procedure.

 

However, unsafe abortion is when:

• Non-medical professionals or unqualified healthcare professionals carry it out.

• It's carried even by a skilled healthcare provider in an unhygienic environment while using unsterilised tools and unhygienic means.

• It leads to unmanaged or poorly managed complications like bleeding (haemorrhage) or damage to surrounding organs.

• You get little to no information about the procedure, your safety, and your potential risk after the procedure.

 

6. How many women and girls die from unsafe abortions in Africa?

Many women and girls who have unsafe abortions do not seek medical attention. They do this because of fear of stigma or legal repercussions.

This means many abortion-related deaths might not be officially recorded. However, a study puts the number at 15,000 preventable deaths per year. (4)

 

Conclusion 

 

Unsafe abortions are a critical public health issue in Africa, causing devastating health complications and even death. These preventable tragedies can be addressed by expanding access to safe and legal abortions, alongside comprehensive sexual and reproductive health education.

 

References:

1. Cunha JP. What is abortion according to WHO? [Internet. n.d.] Emedicinehealth. Cited June 30 2024. Available from here.

2. World Health Organization (WHO). Abortion. [Internet. 2024 May 17]. Cited June 30, 2024. Available from here.

3. Weerasinghe S, Macias-Konstantopoulos W. The preventable burden of mortality from unsafe abortion among female sex workers: a Community Knowledge Approach survey among peer networks in eight countries. Sex Reprod Health Matters. 2023 Dec; 31(1):2250618. doi: 10.1080/26410397.2023.2250618. Available from here. 

4. Bankole A, Remez L, Owolabi O, Philbin J, Williams P. From unsafe to safe abortion in sub-Saharan Africa: slow but steady progress. [Internet. 2020 Dec]. New York. Guttmacher Institute. Cited 2024 June 29.  doi: 10.1363/2020.32446. Available from here. 

5. Armstrong M. Abortion in Africa: 28 years of progress [Internet. 2022 May 18]. Statista Daily Data. Cited 2024 Jun 29. Available from here.

6. Corbett MR, Turner KL. Essential Elements of Post-abortion Care: Origins, Evolution and Future Directions. [Internet. 2003 Sept 1]. Int. Persp Sex Repro Health. 29; 3. Cited June 30 2024. Available from here.

 

Related:

6 Conditions that Put Pregnant African Women at Risk of Death

Maternal Mortality in sub-Saharan Africa: A Call to Action

Social Factors Shaping African Women’s Health

12 Top African Women's Health Issues and How to Take Action

 

 

 

 

Published: July 7, 2024

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