Factors contributing to criminal abortion

Introduction

The rate of pregnancy among adolescents is on daily increase and this is causing major health and social problems in the society. Pregnancy among adolescents is one of the major prevalent health concerns for families as a unit, the society and the government both at local, state and federal level.

According to Fleming and O’Connor (2006) more than one million adolescents ranging between ages of 15–17 years become pregnant. Nigeria Demographic and health survey in 2010 revealed that more than a quarter of Nigeria adolescents ages between 15 and 19 years are pregnant or have had children and that 43% of the pregnancy are unintended or unplanned for. The same agency revealed that adolescents are more likely to resort to induced and unsafe abortion which can result into morbidity and mortality.

Adolescents are sexually active beyond what parents, teachers and religious leaders think, the prevailing situation is due to the fact that they are at a stage of life characterized  by intense sexual drive, peer pressure, a perverse social environment poor reproductive health knowledge, just to mention a few and one of the consequences of the aforementioned is teenage pregnancy.

Overview of abortion in Nigeria

Abortion is the ending of pregnancy by the removal or forcing out from the womb of a foetus or embryo before it is able to survive on its own (Grimes & Stuart, 2010). Abortion is legally defined as the expulsion of the foetus from the uterus (womb) at any time before its time of gestation is complete, for practical purpose this must be reduced to emptying of the uterus prior to the time when the foetus is capable of survival, i.e., sometimes between the twenty- fourth and the twenty eight- weeks of the pregnancy.Performing or seeking an abortion is illegal in Nigeria, except to save a woman’s life. Yet experts estimate that more than 600,000 Nigeria woman obtain abortions criminally each year (Guttmacher Institute, 2010), according to the study, one third of the women obtaining abortions were adolescents. Hospitals base studies showed that up to 80 percent of Nigeria patients with abortion related complication were adolescents (Otoide, 2011).

According to Population Reference Bureau (2012), one third (36.5 million) of Nigerians’ population of 123 million are youth between the ages of 10 and 24. By 2025, the number of Nigeria youth will exceed 57 million (population division, 2010) lack of sexual health information and services places these young people at risk for pregnancy, abortion, sexually transmitted infections (STIs), and HIV/AIDS. In addition, early marriage and child bearing limit youth’s educational and employment opportunities, yet effective, innovate programs can provide youth with the sexual information and services they need.

Lemon and Machaira (2012) stated that more and more adolescent are becoming sexually active, at early age, at a high frequency, with many partners and without the benefit of effective and regular contraception. He went further to say that the result of these encounters is unwanted and unplanned pregnancy. Young girls involved in this practice while still in school thereby depending on their parents and guardians for survival. At times they are not even sure of the father of the expected child as most of such pregnancies are unwanted, unplanned and unintended. The girls are force to terminate the pregnancies by all means because they are not ready for motherhood as that would mean losing out of many opportunities such as education, jobs, marriage. They fear retribution and rebuke by the family and society as a whole, though a few of such girls do carry the pregnancy up to stage of delivery. It is presumed that a good proportion of them do terminate their pregnancy to remedy the already awful situation.

Moronkola and Okanlawon (2006) stated that female adolescents become pregnant due to some socio- economic and sociological factors, this is also a problem, as abortion is not yet legalized by the federal law makers of Nigeria. As such when abortion is done, it is often done in secrecy and usually quacks are consulted , this often lead to sudden death, female adolescents contacting HIV/AIDS, health problem such as Psychological problems, Reproductive tract infections, Heavy bleeding- leading to severe anemia, Toxemias, Vesico- vaginal fistula (VVF) damage uterus, Infertility and sterility.

According to Lemo and Machaira(2012) abortion could be therapeutic in nature to save the mother’s life or done when congenital malfunction of the foetus is diagnosed, it can as well be criminally induced and both can become complete or incomplete abortion. Incomplete abortion can lead or give rise to heavy bleeding, sepsis and other serious medical or gynaecological complications. Bureau on Abortion Population in 2008 stated that estimated 68,000 girls and women die each year from induced unsafe abortion and million suffer complications that require medical attention. More than one quarter of the world population live in countries where abortion is prohibited and only allowed for therapeutic purpose, however regardless of legal status people still carried out abortion and nearly half of them are performed by an unskilled practitioner in an unsanitary environment (WHO, 2008).

According to Udoh (2012) socio-economic status is a component of social environment, which has tremendous, impacts on a person’s health including that of the family. With enhanced socio-economic status, the individual would be able to afford products and services that will improve his health and quality of life. These groups of adolescents seek help from cheap medical health centre without being mindful of the existing skills; frequently they patronize quacks and unskilled health personal with all its attendant consequences, due to their low economic status; traditional medicine practitioner, seek medication and finally they involved in abortion.   In the same vein Adeuga (2010) stated that sociological factor which include society, peer group, religious, culture, parent and family just to mention a few sometimes contribute to misfortune or delinquency in female adolescents. The misfortune include, stealing, truancy, having multiple boyfriends, attending night parties and eventually unwanted pregnancy which often result into criminal abortions and untimely death.

Incidence of abortion

The number of abortions performed worldwide has remained stable in recent years, with 41.6 million having been performed in 2013 and 43.8 million have been performed in 2008. The abortion rate worldwide was 28 per 1000 women, though it was 24 per 1000 women for developed countries and 29 per 1000 women for developing countries. Also the same 2012 study indicated that in 2008, the estimated abortion percentage of known pregnancies was at 21 percent worldwide, with 26 percent in developed countries and 20 percent in developing countries (Sedge,  2012).

According to Guttmascher Institute (2010), in Nigeria about 25 percent out of 1,000 pregnancies are aborted, compared to western countries where abortion is legal and done liberally. There abortion rate is five out of 1,000 pregnancies. Non- legalization of abortion contributes immensely to maternal deaths. We are losing about 60,000 women every year to abortion and 40 percent of these figures are caused by complication from induced abortion. Again same author said 10,000 women die yearly in Nigeria from unsafe abortion; it is believed that an estimated 760,000 induced abortions occur in the country every year. The study says almost 6 in 10 abortions are carried out by medical professionals in hospitals and clinics, 55 percent in private ones and three percent in public ones. Others according to the study are done under much less safe conditions and by methods that are much likely to result in health complications.

On average, the incidence of abortion is similar in countries with restrictive abortion laws and those with more liberal access to abortion. However, restrictive abortion laws are associated with increases in the percentage of abortions which are performed unsafely. The unsafe abortion rate in developing countries is partly attributable to lack of access to modern contraceptives providing access to contraceptives would result about 14.5 million fewer unsafe abortions and 38,000 fewer deaths from unsafe abortion annually worldwide.

Classes of abortion

Olaifa (2013) describes abortion as the termination of a foetus before it reaches the age of maturity. According to him, there are two types of abortion, namely

• Induced abortion
• Non induced abortion

Induced abortion occurs when the pregnant mother decides to terminate the pregnancy without any medical justification while the non induced abortion occurs naturally. According to Russel (2004) for medico- legal purposes, abortions may be grouped into three classes;

• Spontaneous abortion.
• Therapeutic abortion.
• Criminal abortion.

The former include about two-thirds of all abortions. Taussing (2005) estimated that from 34-69 percent of all abortions, with the lesser figure for rural and higher for urban areas, were illegal induced. Others tend to a somewhat lower average figure, but even the most conservative reports do not estimate that over 70 percent of abortion begins without artificial interference with the normal course of events.

• A spontaneous abortion: This is also known as miscarriage, is the unintentional expulsion of an embryo of foetus before 24^th week of gestation. Approximately two-thirds of spontaneous abortion are due to abnormal development or death of the ovum or its membranes, while the remainder are caused by maternal disease, either systemic or involving the womb or its accessories. In many cases it is impossible to discover the underlying cause of the abortion. There is a natural tendency on the part of the pregnant woman to seek a cause whenever an abortion occurs, therefore relatively minor accidents, falls or scares are frequently blamed when premature labour ensures.
• A therapeutic abortion: This is an interruption of pregnancy performed to safeguard the health or save the life of the mother. This definition requires that the abortion be performed by a physician, acting in the honest belief that the life of the pregnant woman will be endanger by the continued presence of the pregnancy, various authorities estimate the incidence of therapeutic abortion as from 1-5 percent of the total. The more common medical indications for therapeutic abortion are the presence of active tuberculosis or severe heart, kidney or circulatory disease in the mother.
• Criminal abortion: This is an unlawful abortion; i.e., the interruption of pregnancy by the mother herself or another person in lay language, the term abortion is generally considered synonymous with criminal abortion. It defines a criminal abortion as one that is illegally induced, that is to say, one which is not justified by the circumstances.

According to Guttmacher Institute (2010) performing or seeking an abortion is illegal in Nigeria. The statues in the various states defining the crime of abortion are similar, they provide that whoever with the intent to cause the termination of a pregnancy unlawfully administers or causes to be given to the pregnant woman any drug or poisonous substance or unlawfully uses any instrument or other means what so ever with this intent shall be guilty of the offense.

Methods by which criminal abortion may be preformed

According to Russell (2004), method by which criminal abortion may be performed includes;

• Physical methods: These may be attempted by the mother herself or by some other person. The procedures are intended to promote venous congestion in the pelvic organ in the hope that the interference with the circulation will initiate uterine contractions. They include extremely hot baths, severe or prolonged exercise, manipulations, adjustments and violence to the lower abdomen, these measures are but rarely successful in accomplishing their purpose unless they produce such severe injury as to endanger the life of or kill the mother.
• Chemical method: Drugs may be employed systemically or locally in the effort to empty the uterus frequently encountered group include the purgatives, castor oil, croton oil, and aloes; the intestinal and pelvic irritants, oil of penny royal, tansy, savin, rue etc., and the drugs which stimulate the muscle of the uterus to contract, including quinine, ergot and pituitary extract. A fourth group of chemicals sometimes used by mouth are the true systemic poisons and administered in the hope that the foetus will less able to withstand the toxic chemical than the mother with consequent of the dead or injured foetus but recovery of the mother such compounds as lead, salt, kerosene, apiol, mercury salts, oil of wintergreen and nitrobenzene comprise this group. The criminally dangerous character of this philosophy of abortion procures merit is at once obvious to all. As with the physical methods for abortion, the use of chemical agent by mouth is rarely efficacious unless they are given in toxic doses sufficient to cause serious illness of the mother.

The local use of chemical agents varies from simple vaginal douches, which has little chance of penetrating the dosed cervix, (lower end of the womb), to the injection of the chemical through douche nozzle or syringe under considerable pressure into the cavity of the uterus itself. The later are in reality operative procedures but employed chemical agents to kill the foetus and thus insure onset of labour. They are effective largely by an escharotics action, the most frequently encountered chemicals or compounds are bichloride of mercury (corrosive sublimate), potassium permanganate, arsenic compounds, silver salts, formaldehyde solution, phenol or cresols (Iysol), oxalic acid, solutions of acids or alkalis and various soaps. Utra-jel, which has been reported as causing numerous maternal deaths, belongs to the later group (Straus, 2002), various similar products may be obtained on the open market, the compounds being sold ostensibly for use as antiseptics and not as abortifacients.

Most of these compounds are highly poisonous if they find their way into the blood stream, the locally applied chemicals are effective agents in production of abortion when used in such fashion that they reach foetus or even short of that if they damage the cervix or vagina and lead to infection and haemorrhage.

• Operative methods: Oliafa (2013) says operative methods are practically all attempted through the vaginal canal and are designed to expel the content of the pregnant uterus either by mechanically dislodging or removing the foetus or by causing its expulsion by stimulating contraction of the uterine muscle. While any method may theoretically be employed by the woman herself, the more technical types of instrumentation are used mainly by professional abortionists.

The type of abortion used, varies with age of pregnancy; thus, in early stages, curettage scraping is frequently employed later in pregnancy, dilation of the cervix, or insertion of a catheter, or other sharp foreign body, to rupture the membranes surrounding the foetus are more likely to be used.

• Curettage: Is the technical term used to describe the process of scraping out the inside of the uterus. It is effected usually under anaesthesia, by using instruments to force open (Dilate) the cervix, followed by repeated introduction with a scraping motion of a semi-sharp spoon shaped instrument (curettle) into the cavity of the uterus, the use of “D and C” for producing abortion is limited to the first few months of pregnancy largely because of the excessive bleeding which follows if the uterine content is not small enough to the scraped out promptly enough that the muscular wall of the organ can contract and close the many blood vessels open by the surgery.
• Forcible dilation of the cervix alone is frequently effective in causing the uterus to empty if the pregnancy has advanced beyond the third month. This may be effected by the introduction of a compressed sponge, by the use of slippery elmsticks, or a laminaria tent, which swell when introduced into the cervix where they absorb water, or by the use of instruments designed for dilating the cervix catheters either of the stiff fibre type or using a wire stiffener (Stylet) if a soft rubber catheters is selected, are frequently used for this purpose. A rubber catheter may be left in the uterus to act as an irritating foreign body; the instruments used by the professional abortionist are usually standard surgical instruments.
• Laceration of the foetal membranes with escape of the “waters”  (Amniotic fluid) may often be effected by passing a long thin sharp object into the uterus, many of these instruments are very crude such as an umbrella rib, darning needle, hat pin or a piece of wire or wood. The danger to the mother incident to lack of cleanliness and the possibility of penetrating the uterus rather than the foetal part by the use of this method is easily appreciated.
• The intra-uterine introduction of irritating substances as a method of inducing abortion was mentioned in relation to chemical methods. This is the most frequently used single method for producing criminal abortions and a great variety of techniques exist. Uterine douches of water, salt solution, soap solution or some antiseptic may be used. The fluids may be introduced via hard plastic nozzle connected directly to large rubber bulbs or via syringes with blunt needles or catheters attached. Air alone may be introduce into the cavity of the uterus in as such as fluid is being introduced, frequently under considerable pressure into the enlarged highly vascular pregnant uterus, it is easy to visualize how a large vein may be entered and the fluid pass directly into the maternal circulation producing a severe shock known as “Embolism”.

Factors contributing to criminal abortion

People give different reason for terminating pregnancies, It is either they are too young, single or married but un interested in having more children as far as Nigeria laws are concerned, induced abortion is legal only if it is done to save the woman’s life and before abortion can take place on medical grounds, the doctor must seek second opinion of another doctor. But in spite of legal restriction, abortion rate is still high in Nigeria for as low as N1,000; a woman procures abortion in private clinic in the country. Olaifa  (2003) gave reason ranging from economic to health and social considerations for the prevalence of abortion in the country despite its illegality.

Olaifa (2013) also cited the problem of poor family planning options as another factors. ‘’A’’ family that cannot take care of their children may want to terminate the pregnancy. If a woman is impregnated by someone that is not her husband, her boyfriend, in case of teenagers, she does not want her parent to know and sometimes, it could be because of promiscuity on the part of the woman. It could also be because of parental disapproval of a relationship.

In one survey sexually experienced teenagers, over 13 percent of women and over 27 percent of men reported exchanging money, gifts, or favours for sex in the previous 12 months. Another factors contributing to criminal abortion is the illegality of abortion in Nigeria. The World Health Organization (2008) believes safe and legal abortion is a fundamental right of woman, irrespective of where they lives, it says unsafe abortion is a ‘’silent pandemic’’. According to the world health body, nearly 42 million women faced with unintended pregnancies have abortions yearly. A 2007 study conducted by the world health organization and Guttmarcher Institute (2010) say that 20 million unsafe abortion take place each year, mostly in countries where abortion is illegal, both bodies claim abortion is safe in countries where its legal, but dangerous in countries where its outlawed and performed clandestinely.

According to WHO (2008), nearly all abortions (92 percent) are safe in developed countries, where as in developing countries, more than half (55 percent) are unsafe.

Health implication of criminal abortion

According to World Health Organization (2008) unsafe abortion is a major cause of injury and death among women worldwide. Although data are imprecise, it is estimated that approximately 20 million unsafe abortions are performed annually, with 97 percent taking place in developing countries. Unsafe abortion is believed to result in approximately 68,000 death and millions of injuries annually.

The risk rate for unsafe abortion, according to the world health body is 1/270 though other source claim unsafe abortion is responsible for one in eight maternal deaths, anti-abortion critics contend that most statistics of people dying from abortion are flawed, as there are no accurate statistics about abortion from countries in the developing world. A recent study titled, ‘’unwanted pregnancy and induced abortion in Nigeria; causes and consequences’’, done by Guttmarcher Institute in 2007 shows that approximately 68,000 women died annually in the world as a result of complications of unsafe abortion; and between two million and seven million women each year survive unsafe abortion but sustain long term damage or disease (Incomplete abortion, infection (Sepsis), haemorrhage, and injury to the internal organs, such as puncturing or tearing of the uterus).

Complication arising from unsafe abortion

According to Olaifia (2013) it could be either immediate or prolonged.

Immediate: this include the following

• severe bleeding
• cervical trauma
• Sepsis

Prolonged: this include the following

• Infection leading to infertility.
• Entopic pregnancy.
• Chronic pelvic pain, death.
• Renal failure, damage to the bladder intestine perforation.

According to Russell (2004) all procedures give rise to fatal complications since the technique used by abortionist is often crude and frequently is without regard to proper cleanliness or sterilization of instruments.

Abortion is a major cause of injury and death among women worldwide and most of these deaths result from;

• Anaesthesia: Occasionally, patients may die in the office during the operation, usually dilatation and curettage. Operative interference may be denied, it may be claimed that the Doctor was compelled to put the patient on the table as a life saving measure to stop excessive vaginal bleeding.
• Haemorrhage: this is a common complication many abortionist sending their patient home immediately after the operation. Frequently no anaesthetic is used, thus increasing the danger of haemorrhage and other complications; bleeding starts shortly after the abortion and may cause death within a few hours. If the abortion is complete, the evidence is usually limited to that of severe bleeding.
• Infection: this is the most common cause of death in criminal abortion, the uterus during pregnancy, particularly in earlier stages, being highly vulnerable to infection. Usually the invading bacteria are carried into the uterus by contaminated instruments. Gas gangrene is occasionally seen as particularly terrible type of infection complicating abortion. Local infection in the uterus after criminal abortion, unless vigorously treated, is regularly followed by spread to the blood stream with death from septicemia, or to the abdominal cavity with generalized peritonitis.
• Embolism: The rapid introduction of any foreign liquid or of air into the circulation by penetration by pressure or perforation of a blood vessel during an abortion is likely to be followed by sudden collapse and death of the patient.

Preventive measures

Okonofua (2011) Preventive measures are as important in dealing with criminal abortion as with any other medical problem. Suggested measures are;

• Consultation centres similar to those in existence in Sweden when women with unwanted pregnancies may go for help. Social workers would be able to counsel women contemplating abortion. Most women contemplating abortion report a lack of any one with whom these problems could be openly and honestly discussed, it is conceivable that with experienced counselling these women might ultimately find that they might which to continue pregnancy to term. Others functions of such a centre would include consideration of adoption, pointing out danger of illegal abortion, and  possibly aid to some clients in securing legal abortions rendering whatever social services assistance that may be required at that period of stress.
• Research should be stimulated and supported toward developing the ‘’ideal’’ contraceptive –simple, acceptable and completely effective.
• Education of the public-sex instruction of children at levels understandable to them (and similarly for adults) is necessary to implement pressure goals. Such education must be thorough and continuous and include information on contraceptives, concepts of planned parenthood, therapeutic abortion and criminal abortion with its possible attendant dangers; It is worth stressing the importance of exposing the problem of criminal abortion, its extent, dangers and suggested remedies, it would have been impossible to make any strides in the fights against cancer, tuberculosis and venereal disease without bringing them into the open. Similarly, it is believe that our success in the campaign against criminal abortion will be directly proportional to the extent that the problem is already.

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