115
Inl J Gynecol Obsret, 1992, 38: 115-l 18 International Federation of Gynecology and Obstetrics
Trends in postabortal Nigeria*
mortality
and morbidity
in Ibadan,
I.F. Adewole Fertility Research Unit, Department
ofObstetricsand Gynaecology,
College of Medicine, University College Hospital, Ibadan (Nigeria)
(Received July lOth, 1991) (Revised and accepted November 14th, 1991)
Abstract
Introduction
Illegally induced abortion at the University College Hospital, Ibadan increased steadily over a IO-year period (1980-1989) despite increasing availability of family planning services. Abortion was the commonest cause of death in the gynecology service during the period of the study and constituted 36.6% of fatalities. The majority of patients (76.2%) did not accept contraceptives. Almost one-third of the illegal terminations were performed by physicians. Although the percentage of deaths decreased, the contribution of physicians to these fatalities increased, and accounted for 6/9 (66.7%) of fatalities in 1989. This circumstance probably signifies a defect in physician training and ability to perform abortion aftercare. Physicians should be trained in abortion care and laws changed in conjunction with greater drive to improve contraceptive utilization and reduce the incidence of unsafely induced abortion.
Abortion is a major reproductive health problem. The magnitude of the problem cannot be accurately determined in many counaccurate tries, especially those without demographic data and those with restrictive abortion laws [3,4]. The World Health Organization (WHO) has estimated that about 500 000 women die each year from pregnancy related causes and 99% of these are in the developing countries of the world [11,17]. As many as 50% of these deaths are due to complications in illegal abortion [9], mostly because these women do not have access to safe procedures, family planning or to adequate treatment of complications if they arise [2]. The tragedy of these deaths is that virtually all are preventable [16]. Estimates of the total annual number of legally and illegally induced abortions throughout the world range from 36 to 53 million [6], and it is also estimated that approximately 20-30% of all pregnancies worldwide are terminated by induced abortion each year [ 131. Induced abortion when safely performed and within the law by trained personnel is a safe procedure. When performed outside the law or by untrained personnel, induced abortion is a major cause of death among women
Keywords: Illegally induced abortion; Nigeria;
Morbidity and mortality; Physician training; Law and family planning. ‘This paper was presented at the VIII CAMAS Congress on the Health of the African Mother and Child at Accra Ghana, December 2-7, 1990. 0020-7292/92/$05.00 0 1992 International
Federation of Gynecology and Obstetrics Printed and Published in Ireland
U61. Article
1 I6
Adewoie
Complications from abortion remain a leading cause of morbidity. Although the incidence of complications is high, accurate data are diflicult to obtain, because only those with patients with serious complications are seen in the tertiary hospitals. Postabortal morbidity includes infertility, chronic disability from pelvic abscesses, peritonitis or severe infection, and traumatic injury to the bowel and genital organs. In Ibadan, Nigeria about 50% of our emergency gynecological admissions are due to abortions. The approach in many countries has been to press for legalization of abortion. It is calculated that a woman in a developing country faces a risk of death 25-250 times greater if she is forced to seek services from an unqualified back street abortionist than if she has access to a skilled provider and hygienic conditions. Moreover, when legal restrictions are reduced, the number of deaths related to induced abortion are reduced. For example the death rate fell by 40% in the United States, 56% in Csecholovakia and 38% in Hungary within a few years following review of abortion legislation. The converse is also true. The death rate increased markedly in Romania following the enactment of a restrictive law in 1966. The situation in Nigeria is complex. Abortion is illegal, but the law turns a blind eye. Abortion practice thrives because physicians and nonphysicians alike are able to operate without hindrance. Prosecution is rare except in the case of complications, especially death. Morbidity and mortality are high [lO,lS]. Legalizing abortion alone may not be sufficient to substantially alter this pattern. We decided to review our data over the last 10 years (1980-1989). Our objective was to evolve a rational approach towards solving the abortion problem and make appropriate suggestions for eliminating the problem of unsafe abortion. Materials and methods An assessment of all abortion cases managInr J Gynecor O&et
38
ed at the University College Hospital, lbadan from 1990- 1989 was carried out. Definition. Abortion refers to the interruption of termination of pregnancy from whatever cause after implantation of the blastocyst in the endometrium and before the resulting fetus has attained viability [14]. In Ibadan a birthweight of 500 g or below and 26 weeks gestation are used to define viability. The information required was obtained from hospital case records, Emergency Unit, Gynecology Ward, and Theatre records. The information extracted included demographic data, type of abortion, pattern of morbidity, mortality, duration of hospital stay, cost of management, qualification and training of abortionist. Results During the period of study, 4448 cases of abortion were managed in the hospital. Of these, 912 were judged to have been illegally induced, based on clinical history and the pattern of presentation or injury. Eight hundred forty of the patients with illegally induced abortion were found to have complete information and formed the basis of this report. Table 1 shows a steady rise in both the number of cases of illegally induced abortion managed and the fatal cases seen during the period. Of the nine [9] deaths recorded in 1989, 6 cases were performed by physicians
Table 1. Year
Number
of cases managed
No. of cases
with fatal cases.
No. of death
(%I
Fatality
1980 1981 1982 1983 1984 1985
43 41 50 55 65 66
6 6 4 7 4 4
13.95 12.77 8.0 12.73 6.15 6.06
1986 1987 I988 1989
80 124 146 164
6 I 6 9
1.50 5.65 4.11 5.49
Postabortal mortality and morbidity
Table 4.
Table 2.
Fatalities in 1989.
Age
Parity
Cause of death/associated complication
19 19 15 18 16 29
O+l o+o o+o o+ 1 l+O 4+1
2s 17 29
l+l o+ 2+
Septicemia Septicemia Septicemia Hemorrhage (acute renal failure) Hemorrhage (hepato-renal failure) Perforated viscus, peritonitis, gangrenous bowel Septicemia Septicemia Septicemia
1 1
and all patients were below the age of 30 (Table 2). The age and parity distribution is shown in Table 3. All the patients were in the 15-48 year age range. Most (79.1%) were aged 15-29 whereas only 36 (4.3%) were above the age of 40. The majority 486 (57.9%) were single while 334 (39.8%) were married. Only 20 (2.4%) were divorced. Four hundred sixty (54.7%) were either unemployed, full time housewives or students; 316 (37.6%) were unskilled workers and 64 (7.6%) were skilled workers; 640 (76.2%) were nonusers of contraceptives; 176 (21 .OO/,)were users while there was no record of contraceptive usage in 24 (2.8%). The abortions were performed by untrained providers in 360 (42.8%) while nurses and chemists were responsible for 54 (6.4%) and 176 (21 .O%) pregnancy terminations, respectively. Only 250 (29.8%) of abortions were performed by physicians. Table 3.
Age and parity distribution.
Age
0
15-19 20-24 25-29 30-34 35-39 40
170 60 16 -
46 15 90 -
4 50 64 32 28 -
Total
246
286
178
1
2
3
4 6 22 26 -
54
5 8 2 20 20
50
Total 10 10
26
220 260 184 56 84 30 840
117
Complications of illegally induced abortion.
Sepsis Hemorrhage requiring transfusion Uterine perforation f bowel perforation Lower genital tract injury Renal failure coma Embolism Death
No.
%
724 296 136
86.2 35.2 16.2
80 3 3 2 59
9.5 0.35 0.35 0.2
The duration of hospital stay ranged from 2 to 93 days. One hundred twelve (13.3%) spent less than 3 days on admission while 322 (38.3%) and 344 (41.0%) spent 3-7 days and 7-14 days, respectively, in the hospital. Sixtytwo (7.4%) were on prolonged hospital admission lasting more than 14 days. The cost of hospital management, usually paid by patients/relations was far above the national monthly minimum wage of N350 (equivalent to US$35). One hundred ten (13.1%) patients spent less than N500 while 418 (49.8%) spent between N500 and NlOOO. Three hundred twelve (37.1%) patients spent well over NlOOO. The complications of illegally induced abortion are shown in Table 4. Sepsis occurred in 86.2% of cases followed by hemorrhage in 35.2%. Injuries to uterus, bowel and lower genital tract occurred in 25.7% of patients. Discussion That abortion is more than a gynecological problem is without question. The long term social and economic consequences of this procedure are probably the number one public health hazard in the developing world [14]. It’ is recognised that the approximately 100 OOO125 000 deaths annually from illegal abortion could be prevented by a multidimensional approach [13,14]. The basic problem is that the abortions were poorly or unsafely performed. Abortion rates often reflect the extent of unwanted pregnancy and serve as an indicator of the urgent need for fertility control ser-
118
Adewole
vices. It is widely held that liberalization of abortion and increased acceptance of family planning services would almost eliminate the danger posed by illegally induced abortion
References
WI. Unfortunately, the experience of many workers in developing countries do not fully support this intention [l 1,151.In Nigeria, induced abortion is illegal and is allowing only to save the life of the woman. Conviction of violation of the law carries the risk of a sentence of 14 years imprisonment [5]. The law however, is unapplied, as physicians and nonphysicians perform abortion at will. Sanctions are only applied if there are serious complications. In effect the fact remains, however, Nigeria could be described as one of the ‘liberal’ countries. However, the incidence of illegally induced abortion and the associated complications are high (28.4-46%) [ 11,151. In the present study, the incidence is 20.5%, with the rate increasing to 39% when those patients suspected to have induced abortions are added. The competence of the physicians in performing abortion care is questionable because they perform 29.8% of induced abortions. They were responsible for 66.7% of fatalities recorded in 1989. It is postulated that lack of training in abortion care might be responsible for the seemingly poor performance of the physicians 161. Liberalizing abortion law would allow for early referral and free flow of information, but it could also result in an increase in the number of cases seeking abortion care. The immediate response should be increased allocation of resources. This ought to be combined with training of physicians and nonphysicians in abortion care. To do otherwise would be to spend scarce resources on managing the complications of unsafe abortion to the detriment of other medical problems [7]. The necessary backup to such a problem would be to make family planning services available and accessible to all.
Int J Gynecol Obstet 38
3 4 5 6 I
8 9 10
11
12 13
14
15
16
17
Adelusi B: Effects of Abortion on subsequent pregnancies. Afr J Med Sci IZ: 65, 1983. Akingba JB: Abortion, maternity and other health problem in Nigeria. Nig Med J 3: 83, 1977. Akingba JB, Gbajumo, SA: Produced abortion: counting the cost. Nig Med J 7: 17, 1970. Fox LP: Abortion deaths in California. Am J Obstet Gynecol 98: 645, 1967. Gyepi-Garbrah B: Adolescent Fertility in Nigeria, pp 29-32. A Pathfinder Fund Publication, 1985. Henshaw SK: Induced abortion: a world review, 1990. Int Fam Plann Perspect 16: 59, 1990. Ladipo OA: Preventing and managing complications of induced abortion in third world countries. Int J Gynecol Obstet Suppi 3: 21, 1989. Liskins LS: Complications of Abortion in Developing Countries. Population Reports, Series F, No. 7, 1980. Mahler H: The safe motherhood initiative: a call for action. Lancet i: 668, 1987. Oronsaye AU, Unuigbe, JA: Maternal mortality due to abortions at the University of Benin Teaching Hospital. Trop J Obstet Gynaecol 5: 23, 1985. Population Reports: Healthier mothers and children through Family Planning Population Information Program, pp 657-695. The Johns Hopkins University. Royston E, Armstrong S eds: Preventing Maternal Deaths. World Health Organization, Geneva, 1989. Starrs A: Preventing the tragedy of maternal deaths. A report on the International Safe Motherhood Conference, Nairobi, Kenya, 1987. Tietx C, Henshaw SK: Induced Abortion: A World Review, 6th edn. Alan Guttmacher Institute, New York, 1986. Unuigbe et al: Preventable factors in abortion related mortality in Africa. Focus on abortion deaths in Benin City Nigeria. Trop J Obstet Gynaecol I: 36, 1988. World Health Organization: Maternal mortality: helping women off the road to death. WHO Chronicle 40: 175, 1986. World Health Organization: Prevention of maternal mortality. Report of a WHO Interregional Meeting, Geneva, 1985, FHE186.1 1-21.
Address for reprints: I.F. Adewole Fertility Research Unit Department of Obstetrics and Gynae-cology College of Medicine University College Hospital Ibadan, Nigeria
Inl J Gynecol Obsret, 1992, 38: 115-l 18 International Federation of Gynecology and Obstetrics
Trends in postabortal Nigeria*
mortality
and morbidity
in Ibadan,
I.F. Adewole Fertility Research Unit, Department
ofObstetricsand Gynaecology,
College of Medicine, University College Hospital, Ibadan (Nigeria)
(Received July lOth, 1991) (Revised and accepted November 14th, 1991)
Abstract
Introduction
Illegally induced abortion at the University College Hospital, Ibadan increased steadily over a IO-year period (1980-1989) despite increasing availability of family planning services. Abortion was the commonest cause of death in the gynecology service during the period of the study and constituted 36.6% of fatalities. The majority of patients (76.2%) did not accept contraceptives. Almost one-third of the illegal terminations were performed by physicians. Although the percentage of deaths decreased, the contribution of physicians to these fatalities increased, and accounted for 6/9 (66.7%) of fatalities in 1989. This circumstance probably signifies a defect in physician training and ability to perform abortion aftercare. Physicians should be trained in abortion care and laws changed in conjunction with greater drive to improve contraceptive utilization and reduce the incidence of unsafely induced abortion.
Abortion is a major reproductive health problem. The magnitude of the problem cannot be accurately determined in many counaccurate tries, especially those without demographic data and those with restrictive abortion laws [3,4]. The World Health Organization (WHO) has estimated that about 500 000 women die each year from pregnancy related causes and 99% of these are in the developing countries of the world [11,17]. As many as 50% of these deaths are due to complications in illegal abortion [9], mostly because these women do not have access to safe procedures, family planning or to adequate treatment of complications if they arise [2]. The tragedy of these deaths is that virtually all are preventable [16]. Estimates of the total annual number of legally and illegally induced abortions throughout the world range from 36 to 53 million [6], and it is also estimated that approximately 20-30% of all pregnancies worldwide are terminated by induced abortion each year [ 131. Induced abortion when safely performed and within the law by trained personnel is a safe procedure. When performed outside the law or by untrained personnel, induced abortion is a major cause of death among women
Keywords: Illegally induced abortion; Nigeria;
Morbidity and mortality; Physician training; Law and family planning. ‘This paper was presented at the VIII CAMAS Congress on the Health of the African Mother and Child at Accra Ghana, December 2-7, 1990. 0020-7292/92/$05.00 0 1992 International
Federation of Gynecology and Obstetrics Printed and Published in Ireland
U61. Article
1 I6
Adewoie
Complications from abortion remain a leading cause of morbidity. Although the incidence of complications is high, accurate data are diflicult to obtain, because only those with patients with serious complications are seen in the tertiary hospitals. Postabortal morbidity includes infertility, chronic disability from pelvic abscesses, peritonitis or severe infection, and traumatic injury to the bowel and genital organs. In Ibadan, Nigeria about 50% of our emergency gynecological admissions are due to abortions. The approach in many countries has been to press for legalization of abortion. It is calculated that a woman in a developing country faces a risk of death 25-250 times greater if she is forced to seek services from an unqualified back street abortionist than if she has access to a skilled provider and hygienic conditions. Moreover, when legal restrictions are reduced, the number of deaths related to induced abortion are reduced. For example the death rate fell by 40% in the United States, 56% in Csecholovakia and 38% in Hungary within a few years following review of abortion legislation. The converse is also true. The death rate increased markedly in Romania following the enactment of a restrictive law in 1966. The situation in Nigeria is complex. Abortion is illegal, but the law turns a blind eye. Abortion practice thrives because physicians and nonphysicians alike are able to operate without hindrance. Prosecution is rare except in the case of complications, especially death. Morbidity and mortality are high [lO,lS]. Legalizing abortion alone may not be sufficient to substantially alter this pattern. We decided to review our data over the last 10 years (1980-1989). Our objective was to evolve a rational approach towards solving the abortion problem and make appropriate suggestions for eliminating the problem of unsafe abortion. Materials and methods An assessment of all abortion cases managInr J Gynecor O&et
38
ed at the University College Hospital, lbadan from 1990- 1989 was carried out. Definition. Abortion refers to the interruption of termination of pregnancy from whatever cause after implantation of the blastocyst in the endometrium and before the resulting fetus has attained viability [14]. In Ibadan a birthweight of 500 g or below and 26 weeks gestation are used to define viability. The information required was obtained from hospital case records, Emergency Unit, Gynecology Ward, and Theatre records. The information extracted included demographic data, type of abortion, pattern of morbidity, mortality, duration of hospital stay, cost of management, qualification and training of abortionist. Results During the period of study, 4448 cases of abortion were managed in the hospital. Of these, 912 were judged to have been illegally induced, based on clinical history and the pattern of presentation or injury. Eight hundred forty of the patients with illegally induced abortion were found to have complete information and formed the basis of this report. Table 1 shows a steady rise in both the number of cases of illegally induced abortion managed and the fatal cases seen during the period. Of the nine [9] deaths recorded in 1989, 6 cases were performed by physicians
Table 1. Year
Number
of cases managed
No. of cases
with fatal cases.
No. of death
(%I
Fatality
1980 1981 1982 1983 1984 1985
43 41 50 55 65 66
6 6 4 7 4 4
13.95 12.77 8.0 12.73 6.15 6.06
1986 1987 I988 1989
80 124 146 164
6 I 6 9
1.50 5.65 4.11 5.49
Postabortal mortality and morbidity
Table 4.
Table 2.
Fatalities in 1989.
Age
Parity
Cause of death/associated complication
19 19 15 18 16 29
O+l o+o o+o o+ 1 l+O 4+1
2s 17 29
l+l o+ 2+
Septicemia Septicemia Septicemia Hemorrhage (acute renal failure) Hemorrhage (hepato-renal failure) Perforated viscus, peritonitis, gangrenous bowel Septicemia Septicemia Septicemia
1 1
and all patients were below the age of 30 (Table 2). The age and parity distribution is shown in Table 3. All the patients were in the 15-48 year age range. Most (79.1%) were aged 15-29 whereas only 36 (4.3%) were above the age of 40. The majority 486 (57.9%) were single while 334 (39.8%) were married. Only 20 (2.4%) were divorced. Four hundred sixty (54.7%) were either unemployed, full time housewives or students; 316 (37.6%) were unskilled workers and 64 (7.6%) were skilled workers; 640 (76.2%) were nonusers of contraceptives; 176 (21 .OO/,)were users while there was no record of contraceptive usage in 24 (2.8%). The abortions were performed by untrained providers in 360 (42.8%) while nurses and chemists were responsible for 54 (6.4%) and 176 (21 .O%) pregnancy terminations, respectively. Only 250 (29.8%) of abortions were performed by physicians. Table 3.
Age and parity distribution.
Age
0
15-19 20-24 25-29 30-34 35-39 40
170 60 16 -
46 15 90 -
4 50 64 32 28 -
Total
246
286
178
1
2
3
4 6 22 26 -
54
5 8 2 20 20
50
Total 10 10
26
220 260 184 56 84 30 840
117
Complications of illegally induced abortion.
Sepsis Hemorrhage requiring transfusion Uterine perforation f bowel perforation Lower genital tract injury Renal failure coma Embolism Death
No.
%
724 296 136
86.2 35.2 16.2
80 3 3 2 59
9.5 0.35 0.35 0.2
The duration of hospital stay ranged from 2 to 93 days. One hundred twelve (13.3%) spent less than 3 days on admission while 322 (38.3%) and 344 (41.0%) spent 3-7 days and 7-14 days, respectively, in the hospital. Sixtytwo (7.4%) were on prolonged hospital admission lasting more than 14 days. The cost of hospital management, usually paid by patients/relations was far above the national monthly minimum wage of N350 (equivalent to US$35). One hundred ten (13.1%) patients spent less than N500 while 418 (49.8%) spent between N500 and NlOOO. Three hundred twelve (37.1%) patients spent well over NlOOO. The complications of illegally induced abortion are shown in Table 4. Sepsis occurred in 86.2% of cases followed by hemorrhage in 35.2%. Injuries to uterus, bowel and lower genital tract occurred in 25.7% of patients. Discussion That abortion is more than a gynecological problem is without question. The long term social and economic consequences of this procedure are probably the number one public health hazard in the developing world [14]. It’ is recognised that the approximately 100 OOO125 000 deaths annually from illegal abortion could be prevented by a multidimensional approach [13,14]. The basic problem is that the abortions were poorly or unsafely performed. Abortion rates often reflect the extent of unwanted pregnancy and serve as an indicator of the urgent need for fertility control ser-
118
Adewole
vices. It is widely held that liberalization of abortion and increased acceptance of family planning services would almost eliminate the danger posed by illegally induced abortion
References
WI. Unfortunately, the experience of many workers in developing countries do not fully support this intention [l 1,151.In Nigeria, induced abortion is illegal and is allowing only to save the life of the woman. Conviction of violation of the law carries the risk of a sentence of 14 years imprisonment [5]. The law however, is unapplied, as physicians and nonphysicians perform abortion at will. Sanctions are only applied if there are serious complications. In effect the fact remains, however, Nigeria could be described as one of the ‘liberal’ countries. However, the incidence of illegally induced abortion and the associated complications are high (28.4-46%) [ 11,151. In the present study, the incidence is 20.5%, with the rate increasing to 39% when those patients suspected to have induced abortions are added. The competence of the physicians in performing abortion care is questionable because they perform 29.8% of induced abortions. They were responsible for 66.7% of fatalities recorded in 1989. It is postulated that lack of training in abortion care might be responsible for the seemingly poor performance of the physicians 161. Liberalizing abortion law would allow for early referral and free flow of information, but it could also result in an increase in the number of cases seeking abortion care. The immediate response should be increased allocation of resources. This ought to be combined with training of physicians and nonphysicians in abortion care. To do otherwise would be to spend scarce resources on managing the complications of unsafe abortion to the detriment of other medical problems [7]. The necessary backup to such a problem would be to make family planning services available and accessible to all.
Int J Gynecol Obstet 38
3 4 5 6 I
8 9 10
11
12 13
14
15
16
17
Adelusi B: Effects of Abortion on subsequent pregnancies. Afr J Med Sci IZ: 65, 1983. Akingba JB: Abortion, maternity and other health problem in Nigeria. Nig Med J 3: 83, 1977. Akingba JB, Gbajumo, SA: Produced abortion: counting the cost. Nig Med J 7: 17, 1970. Fox LP: Abortion deaths in California. Am J Obstet Gynecol 98: 645, 1967. Gyepi-Garbrah B: Adolescent Fertility in Nigeria, pp 29-32. A Pathfinder Fund Publication, 1985. Henshaw SK: Induced abortion: a world review, 1990. Int Fam Plann Perspect 16: 59, 1990. Ladipo OA: Preventing and managing complications of induced abortion in third world countries. Int J Gynecol Obstet Suppi 3: 21, 1989. Liskins LS: Complications of Abortion in Developing Countries. Population Reports, Series F, No. 7, 1980. Mahler H: The safe motherhood initiative: a call for action. Lancet i: 668, 1987. Oronsaye AU, Unuigbe, JA: Maternal mortality due to abortions at the University of Benin Teaching Hospital. Trop J Obstet Gynaecol 5: 23, 1985. Population Reports: Healthier mothers and children through Family Planning Population Information Program, pp 657-695. The Johns Hopkins University. Royston E, Armstrong S eds: Preventing Maternal Deaths. World Health Organization, Geneva, 1989. Starrs A: Preventing the tragedy of maternal deaths. A report on the International Safe Motherhood Conference, Nairobi, Kenya, 1987. Tietx C, Henshaw SK: Induced Abortion: A World Review, 6th edn. Alan Guttmacher Institute, New York, 1986. Unuigbe et al: Preventable factors in abortion related mortality in Africa. Focus on abortion deaths in Benin City Nigeria. Trop J Obstet Gynaecol I: 36, 1988. World Health Organization: Maternal mortality: helping women off the road to death. WHO Chronicle 40: 175, 1986. World Health Organization: Prevention of maternal mortality. Report of a WHO Interregional Meeting, Geneva, 1985, FHE186.1 1-21.
Address for reprints: I.F. Adewole Fertility Research Unit Department of Obstetrics and Gynae-cology College of Medicine University College Hospital Ibadan, Nigeria
