Unsafe Abortion and Maternal Death: A Review of Avoidable Anguish and Death

Abortion is the removal of an embryo from the uterus before it reaches viability (in human beings, usually about the 20th week of gestation). An abortion can happen naturally, in which case it’s also known as a miscarriage, or it can be forced, in which case it’s known as an induced abortion.

Miscarriages or spontaneous abortions may occur for a variety of causes, including cancer, accident, genetic deficiency, or biochemical incompatibility between the mother and the fetus. A failed abortion occurs where an embryo dies in the uterus but is not successfully removed.

Induced abortions can be performed for a variety of reasons, including preserving the mother’s life or physical or mental well-being, preventing the completion of a pregnancy caused by rape or incest, preventing the birth of a child with serious deformity, mental deficiency, or genetic abnormality, or preventing a birth for social or economic reasons (such as the extreme youth of the pregnant female or the sorely strained resources of the family unit). Abortions administered to protect the female’s health or in situations of abuse or incest are therapeutic, or justifiable, abortions, according to some theories.

According to The World Health Organization (WHO) unsafe abortion is describes as a procedure of pregnancy termination either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards or both. An unsafe abortion is a procedure that puts the woman’s life in danger. Self-induced abortions, abortions performed in unsanitary circumstances, and abortions performed by a medical provider that fails to offer adequate post-abortion care are all examples. Every year, about 25 million unsafe abortions occur, the majority of which occur in developing countries. Every year, about 7 million women suffer complications as a result of unsafe abortions. Unsafe abortions are also one of the main causes of pregnancy and childbirth-related deaths (about 5-13 percent of all deaths during this period). The majority of unsafe abortions occur in countries where abortion is illegal, or in developing countries where affordable and well-trained medical personnel are scarce, or where conventional birth control is inaccessible. Abortion that is unsafe is a public health emergency. Access to legal abortion was and continues to be a public health concern. The more stringent the rule, the more deaths and other complications occur.

Common Methods Employed during Unsafe Abortion

In order to perform abortion by unskilled personnel, below are some of the unsafe method employed which are in most cases risky and consequently leading to several complications including maternal deaths:

  • The use of sharp objects
  • Injecting toxic chemicals into the woman’s body
  • Self-medication of perceived abortion causing drug/substances

The Use of Sharp Objects

Using a sharp point or wire to sever the amniotic sac within the womb (for example an unbent wire clothes hanger or knitting needle). This procedure can result in inflammation or damage to internal organs (such as perforating the uterus or intestines), which can lead to death. Since the uterus softens and is easier to pierce during pregnancy, another commonly practice technique was to use a large feather.

Injecting Toxic Chemicals into the Woman’s Body

Injecting noxious substances into the woman’s body; such as chili peppers and substances like Lysol, permanganate, or plant poison. This approach in most instances put the woman into toxic shock that can cause her death.

Self-Medication of Perceived Abortion Causing Drug/Substances

Self-administering abortifacient over-the-counter or unlawfully administered medications, or using drugs not recommended for abortion but believed to cause miscarriage or uterine contraction, to induce an abortion without medical oversight. oxytocin (Pitocin and Syntocinon are synthetic forms), prostaglandins, and ergot alkaloids are all drugs that induce uterine contractions. Uterine rupture, erratic pulse, high blood pressure (hypertension), low blood pressure (hypotension), transfusion-dependent anemia, coronary complications, pulmonary edema, and mortality, as well as severe bronchospasms in women with asthma, are all risks common with these practices.

Prevalence of Unsafe Abortion and Maternal Deaths

Each year, 210 million women around the world become pregnant. 80 million of these pregnancies are unexpected. Each year, 46 million pregnancies are aborted, with 19 million ending in an unsafe abortion. In developing countries, more than 97 percent of unsafe abortions occur. Abortion without medical supervision rose from 44% in 1995 to 49% in 2008. In 2000, the WHO estimated that one out of every ten pregnancies ends in an unsafe abortion, resulting in a one-to-seven ratio of unsafe abortions to live births. Similarly, 68,000 women die each year as a result of unsafe abortions, and the incidence of maternal mortality is very high in developing countries (1 in 270 unsafe abortions). In Sub-Saharan Africa (SSA), 37 deaths per 100,000 live births were linked with unsafe abortion, compared to 23 deaths per 100,000 in Latin America and the Caribbean and 12 deaths per 100,000 in South Asia. According to the World Health Organization (WHO), unsafe abortion accounts for 13% of all maternal deaths worldwide. However, the contribution to unsafe abortion in Africa is excessive, with 2.4 million unsafe abortions occurring in Eastern Africa in 2008. Around the world, 40% of reproductive-age women live in countries with stringent abortion laws.

Over 4 million unsafe abortions are performed in Africa each year, mostly on vulnerable, rural, and young women who are unaware of the availability of safe abortion services. In Africa, about 99 percent of all abortions are unsafe, and the chance of maternal mortality from an unsafe abortion is one in every 150 procedures, the highest rate in the world. Poverty, socioeconomic inequity, and lack of women’s civil rights all contribute to the prevalence of illegal abortion.

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Women’s health is jeopardized by abortion restrictions or unsafe, covert abortions, particularly among young, poor, and low-education women. Various means of unsafe abortion are used, including the use of oral and injectable products, vaginal preparations, intrauterine foreign bodies, and abdominal trauma. A significant number of women (20–50%) who have an unsafe abortion experience complications that need hospitalization. Hemorrhage, sepsis, peritonitis, and damage to the cervix, vagina, fetus, and abdominal organs are among the risks. By 2030, the Sustainable Development Goals (SDGs) hope to lower the global maternal mortality rate from 216 to 70 per 100,000 live births.

Factors Contributing to the Prevalence of Unsafe Abortions

Factors that necessitate women to use an unsafe abortion method even in countries where there is availability of safe abortion procedures are discussed below:

  • Economic Reasons
  • Socio-cultural Factors
  • Educational Qualification
  • Healthcare Services
  • Legal Restriction

Economic Reasons

Poverty is one of the reasons why women, developing world, seek unsafe abortions despite the availability of safe abortion methods. The cost of abortion care is equal to the provider’s qualifications and expertise. In general, when services are offered by a licensed practitioner or a qualified nurse, the cost is higher; but, when services are provided by a traditional healer, a non-trained provider, or by the women themselves, the cost is lower. According to a survey undertaken in Nigeria on health care providers’ perceptions of induced abortion, the majority of wealthy women in both rural and urban areas use the services of trained health professionals while the poor in rural and urban areas cannot bear the exorbitant fees charged by practitioners, they turn to untrained workers or herbalists for assistance.

Age and maturity are also important factors in making abortion unsafe. Married or older women are more privileged and can afford private medical care, while young girls in school do not have the financial means to pay such high hospital fees. Furthermore, young girls may lack the experience to understand pregnancy at an early stage; the majority of young girls discover they are pregnant at a later stage, sometime in the second trimester. As a result, young, inexperienced women are more likely to suffer complications from a late, unsafe abortion.

Socio-cultural Factors

The stigma linked to terminating a pregnancy within the society is one of the reasons why abortion is dangerous. For fear of being revealed, women do not share their pregnancy with others due to a secrecy concern. Because of the same apprehension, they wait until the pregnancy is too far advance before seeking medical help, which raises the risk of complications. Despite the provision of safe procedures in their neighborhoods, they often choose the assistance of unqualified workers located outside of their communities due to stigma. The assumption is that if they go see a medical professional, they will find out they are pregnant. Even when a complication occurs, they wait until it becomes life-threatening before seeking medical help. Many of these conditions add to the dangers of abortion. In certain parts of the world, religion is another barrier to accessing legal abortion; most religious groups believe abortion to be a sin. Because of their religious beliefs, women in religiously conservative countries would find it challenging to obtain a safe abortion.

Educational Qualification

When it comes to deciding the safety of abortion, a person’s educational background is crucial. Evidence suggests that educated women make every effort to seek safe abortion facilities. Being educated gives them the privilege of being able to tell the difference between reputable health professionals and quacks, as well as being mindful of the dangers of unsafe abortions. At the same time, they are more likely to talk to their peers about the subject in order to get helpful advice on where to get a safe abortion. Furthermore, educated people are more likely to live to be financially self-sufficient. In this respect, they can afford to pay for safe abortion care in hospitals.

Healthcare Services

Another barrier to accessing safe abortion services in the developing nations of the world is poor quality and non-availability of health services. The majority of the private hospitals in these parts of the world that provide the services are not sufficiently equipped and the doctors or the midwives are not well trained to handle such cases. One of the safest means of pregnancy termination is the manual vacuum aspiration (MVA), but most of the doctors prefer dilation and curettage (D&C) because they don’t know how to carry out an MVA. Sometimes the distance women have to travel to access the services is the main barrier to obtaining safe abortion especially in the rural areas.

Legal Restriction

Abortion services are commonly held in very high secrecy at exorbitant prices in some countries around the world as a result of a form of legal prohibition, and qualified practitioners are not available for the majority of people who need them. This indicates that a woman in need of an abortion would depend on the services of untrained professionals in an under-equipped environment. Due to social stigma and a rigid legal environment, even accurate knowledge about abortion is difficult to obtain. This is one of the reasons for the high number of abortion complications in countries where abortion is illegal. As a result, nations where abortion is illegal will continue to have the world’s highest rate of unsafe abortion. In the other hand, nations with liberal abortion laws would see a lower rate of unsafe abortions and maternal deaths as a result of unsafe abortions.

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Impact of Unsafe Abortions on the Reproductive Health of Women

Unsafe abortion leads to several consequences on the reproductive health of women. The consequences can be classified both on short and long basis.

Early Complications

According to WHO, worldwide unsafe, clandestine abortions carry a lot of risks to the health lives of the women involved. The main factors responsible for most of the problems are: chronic ill health of the women, existing sexually transmitted diseases, skills and experience of the providers, the methods involved, hygienic conditions, gestational age of the pregnancy and the legality of the procedure.  Following an abortion, some women have been confirmed to experience one or more complications, ranging from serious bleeding to high-grade fever to damage to the visceral organs. As the gestational age of the pregnancy increases, the complications get more serious. The degree and magnitude of the complications are often determined by the providers’ procedures and capabilities. Hemorrhage, sepsis, uterine perforation, bowel perforation, damage to the cervix caused mostly by the tools used, severe renal failure, bladder injury, deep vein thrombosis, tetanus, bowel fistulae, and death from anesthesia are the most frequent early complications with unsafe abortion.

Late Complications

Some of the late complications of unsafe abortion include secondary infertility, chronic pelvic pains, chronic pelvic inflammatory diseases and maternal mortality, which is devastating for the woman and her family.

  • Secondary Infertility: Secondary infertility is one of the most severe side effects of unsafe abortions around the globe. According to WHO estimate, 20-30% of unsafe abortions cause reproductive tract infections and 20-40% of which is responsible for the upper genital tract infection and secondary infertility. The various methods used by both professional and untrained illicit abortionists, such as injecting various instruments in the uterus, have been blamed for the rising incidence of secondary infertility attributable to abortion. Cervical dilatation, the use of chemicals, and conventional medicines are some of the other methods used to induce abortions. Foreign bodies, such as needles, bones, and the back of a tree, are occasionally inserted. Multiple injuries to the reproductive organs, including the vagina, tubes, and uterus, occur. Long-term complications from such injuries range from vaginal atresia, uterine synecae, cervical incompetence and cervical fibrosis to full tubal blockage, both of which can lead to secondary infertility. Infertility can occur when the uterus is removed completely to treat complications from unsafe abortions.
  • Maternal Mortality: According to the WHO, maternal mortality is the death of a woman while pregnant or within forty two days of termination of the pregnancy, irrespective of the site or duration of the pregnancy, from causes that are directly related or aggravated by the pregnancy or its management, but not from accidental or incidental causes”. Maternal mortality from unsafe abortion is a serious global problem that continues to threaten the lives of many women. The WHO stated that every eight minutes a woman is dying of unsafe abortion, at the rate of 367 maternal deaths per 100,000 unsafe abortions. And more than 97% are in the developing countries with restrictive abortion laws and poorly organized healthcare services. Among those that survive the early complications; over 5 million will suffer serious long-term complications.
  • Ectopic Pregnancy: Ectopic pregnancy in future pregnancies is another serious long-term complication of unsafe illegal abortion. “An ectopic pregnancy is a pregnancy that develops outside the uterus (womb) and is potentially fatal to the woman.” Ectopic pregnancy, early labour, and repeated spontaneous abortion are also risks of unsafe abortion in future pregnancies. In women who had vaginal abscess and adhesions as a result of a complex unsafe abortion, post-abortive infection raises the risk of ectopic pregnancy five-fold.
  • Chronic Pelvic Inflammatory Disease: Pelvic inflammatory disease (PID) is “an infection of the woman’s reproductive organs (uterus, fallopian tubes and ovaries) and upper genital tract”. PID is one of the late complications of unsafe abortions. Lower stomach pains, vaginal discharge, and adnexal tenderness are typical symptoms. PID is caused by an infection that either already exists in the women’s reproductive tract or is transmitted by the abortionist by the instruments used to terminate the pregnancy. The infection can also be traced back to the unsanitary condition in which the abortion was undertaken. It can also lead to recurrent pelvic pain and secondary infertility if not treated properly.

Prevention of Unsafe Abortion and its Associates Maternal Deaths

It is well known that unsafe abortion is one of the main causes of maternal mortality and severe morbidity in countries with restrictive abortion laws. Below are some of the measures if put in place can help in the prevention of unsafe abortion and it associated maternal morbidities and mortalities.  This measures include but not limited to the following:

  • Promotion of Effective Use of Contraception
  • Provision of Social Security to Pregnant Women
  • Promotion of the Use of Adoptive Services
  • Provision of Safe Abortion Service
  • Adequate Clarification of Abortion Laws
  • Prompt Treatment of Abortion Related Complications
  • Prevention of Repeat Abortions

Promotion of Effective Use of Contraception

Effective use of contraceptives can help the reduction of unwanted pregnancies and consequently unsafe abortions. The clearest example has been the dramatic drop in the abortion rate in Eastern Europe following the introduction and increasing adoption of effective contraceptives in those countries in recent years. Some of the most common and effective contraceptive methods include the use of contraceptive pills, intrauterine device (IUD) and contraceptive implants, the use of barrier method, etc.

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Provision of Social Security to Pregnant Women

Another technique for reducing induced abortion by pregnant women is to provide social security to those who choose to have a child but have been deserted by their partners, abandoned by their families, and see abortion as their only option for survival.

Promotion of the Use of Adoptive Services

Women with unwanted pregnancy should be encouraged use adoption services rather than resort to abortion. Many programs offer women with unintended pregnancies the opportunity to continue their pregnancies to term and give their babies up for adoption. After birth, the babies are placed in orphanages to wait for foster parents.

Provision of Safe Abortion Service

When a woman has made the decision to terminate an unintended and unwanted pregnancy, she will do so at all costs. In this case, the best way to avoid an unsafe abortion is to provide safe pregnancy termination services. The International Conference on Population and Development (ICPD), held in Cairo in 1994, includes the following statement in its Programme of Action: “In circumstances in which abortion is not against the law, such abortion should be safe”.

Adequate Clarification of Abortion Laws

Just a few nations prohibit abortion under any cases. However, in many countries with stringent rules, neither women nor health care providers are aware of these situations, and most women cannot have a safe, legal abortion, even though they meet all of the requirements. Many nations, for example, allow abortion when a pregnancy is the product of incest, but the rule isn’t enforced because it’s unregulated—often, a judge’s prosecution of the perpetrator is expected, by which time the pregnancy has already progressed to term. In most countries with restrictive laws, the absence of standard guidelines or legislation for carrying out legal abortions renders those services virtually non-existent, forcing women who have the legal right to a safe abortion to resort to dangerous procedures. Even in countries where the law is permissive, such as India, Zambia, or South Africa, full implementation of the law has been postponed for years because the health sector is unprepared to deliver these facilities, and providers are unable to provide care inside the public health system. Physicians’ reluctance to administer abortions is often justified by a lack of consistent legislation and a concern that their peers will discriminate against those who perform abortions in public facilities.

Prompt Treatment of Abortion Related Complications

When complications from an illegal abortion arise, they should be treated as a health emergency and treated as soon as possible to prevent further progression of the situation and a tragic outcome. When all other options have failed and a woman has had an unsafe abortion, the treatment she gets when she meets with an abortion complication will decide the final result. The ICPD Programme of Action states that: “In all cases, women should have access to quality services for the management of complications arising from abortion”. Providing high-quality post-abortion treatment necessitates the use of cutting-edge equipment to complete uterine evacuation when necessary (i.e. to replace dilation and curettage [D&C] with vacuum aspiration or the use of medication). The positive behavior of health professionals is a second and similarly critical feature of successful postabortion treatment. Women seeking medical help for abortion complications are discriminated against in many countries where abortion is illegal, and they are often detained, processed, and imprisoned. Discrimination against women with abortion complications has two factors that influence the severity of abortion morbidity and mortality: (1) When women are aware that they will be targeted or that the police may get involved, they tend to stop using community facilities and wait until they are seriously sick before seeking help; and (2) Women who have had abortion problems are placed at the back of the queue for treatment, prolonging the “third delay” in the sequence of events that leads to maternal deaths.

Prevention of Repeat Abortions

Intervention services should be implemented to help prevent repeat abortion by giving women who have already had an abortion the information they need to control their fertility in a manner that is both appropriate and desirable to them. By undergoing an abortion, a woman is telling us that she did not want to have a baby and that she was unable to prevent the pregnancy that was terminated. Women who have had abortions should be counseled on family planning, told of the various contraception options available, and given the tools to manage their fertility. The 1994 ICPD Programme of Action states: “Post‐abortion counseling, education and family‐planning services should be offered promptly, which will also help to avoid repeat abortions”.

Counseling should be objective and unbiased to the greatest extent possible. The most important piece of information to convey is that pregnancy returns nearly immediately following an abortion, with first ovulation coming as early as the second week after the procedure. It is important to include information on the efficacy of the various contraceptive methods available. The potential user will weigh a variety of factors, including effectiveness. People who have had abortions are reminding us by their acts that they value the avoidance of a new birth; thus, reliable research on efficacy is required for these women.

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