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14 October 2013 | Feature Article

Unsafe Abortions

Unsafe Abortions

Abortion refers to the expulsion of a foetus (baby) from the womb at a time that it is not capable of surviving outside the womb. In Ghana, most babies delivered before 28 weeks of gestation are not able to survive without assistance. An abortion may be spontaneous or induced. Spontaneous abortion is often called a miscarriage, and it is often said 'the pregnancy got 'spoilt' and comes out by itself'. An induced abortion, also known as a termination of pregnancy, is an interruption of pregnancy for one reason or the other. Here, the pregnancy would have travelled its full length of time, but for an intervention to stop it from doing so.

An induced abortion may be safe or unsafe. A safe abortion is one that is done by a qualified provider with the requisite skills, and done in an environment that meets the minimal medical conditions for the procedure. A safe abortion is as safe as taking an injection in a hospital.

An unsafe abortion is an abortion that is done by a person without the needed skill or training, or in an environment that lacks the minimal medical conditions for the procedure, or both. This means a quack health worker who performs an abortion in a hospital theatre makes the process unsafe. Likewise, a well trained gynaecologist who performs the same procedure in his home garage makes the process unsafe.

Burden of unsafe abortions
Every year, worldwide, about 42 million women with unintended pregnancies choose abortion, and nearly half of these procedures, 20 million, are unsafe. Some 68,000 women die of unsafe abortions annually, making it one of the leading causes of maternal mortality (13%). Of the women who survive unsafe abortion, 5 million will suffer long-term health complications.  

According to the World Health Organisation (WHO), every 8 minutes a woman in a developing nation will die of complications arising from an unsafe abortion. In Western nations, only 3% of abortions are unsafe, whereas in developing nations, 55% are unsafe.

Why do women go in for abortions?
Most women go in for an abortion if they have unintended pregnancies. More than one-third of all pregnancies are unintended, and 1 in 5 ends in abortion. Unintended pregnancies come about as a result of a myriad of reasons. Teenagers experimenting with sex may get pregnant, non-use or failure of contraceptive methods may lead to unintended pregnancies. Engaging in transactional sex may also lead to unintended pregnancies. Some terminate their pregnancies to avoid the social stigma that comes with pregnancies before marriage, and these may even be sought by parents or guardians of the pregnant woman.

Studies have shown that once a woman makes up her mind to terminate a pregnancy, she is very likely to employ all means necessary to get rid of it.

What are some of the unsafe abortion methods used
Some try to mechanically disrupt their pregnancies. Some try to break the   amniotic sac (the sac containing the liquid in which the baby lies) inside the womb by themselves with a sharp object such as a wire, coat hanger, knitting needle , bamboo sticks, large feathers, chicken bone etc. This method can result in infection or injury to internal organs (for example perforating the uterus   or intestines ), resulting in death. Where the help of an untrained person is sought, they may also attempt to terminate the pregnancy by use of instruments. This is also dangerous, because one will need to know the anatomy of the female pelvic organs in order to determine the direction to insert the instruments. An untrained person may end up perforating the uterus and other important organs, which may lead to death. The uterus softens during pregnancy, and is very easy to pierce.

Some apply blunt trauma to the pregnancy through the abdomen by hitting the tummy with an object, or intentionally falling on the abdomen from a height like jumping from the roof of a house, etc.

Another means of unsafe abortion is the use of toxic concoctions. These include herbal preparations, absurd concoctions such as finely ground glass, caustic soda, hot pepper, highly concentrated sugar solutions, laundry blue, animal dung or droppings, etc. There are some herbs that have abortion-inducing properties which are known to some women, who use them to abort pregnancies.   These concoctions are drunk or inserted into the vagina, or into the rectum using enemas.

Nowadays, most women abort their pregnancies using a drug known as cytotec or misoprostol. This drug was licensed for the treatment of stomach ulcer, but was noted to make the neck of the womb weak and lead to the expulsion of the contents of the uterus. Cytotec is used in hospitals for induction of labour (what is locally referred to as 'forced-labour'). It is also used to stop excessive bleeding after delivery that can lead to death in childbirth. Though a prescription drug, it is commonly available, and is used a lot by young women to abort unwanted pregnancies.

Dangers of unsafe abortions
Unsafe abortion is a major cause of injury and death among women worldwide. Although data is imprecise, it is estimated that approximately 20 million unsafe abortions are performed annually, with 97% taking place in   developing countries like Ghana. Unsafe abortions are believed to result in approximately 69,000 deaths, and millions of injuries annually.

The womb of a woman is such that until all the parts of the baby, placenta and clots are expelled, it will not stop bleeding. Thus, most unsafe abortions result in some of the products of conception being left behind. If the woman does not seek post-abortion health care on time, she will continue to bleed little by little till all her blood runs out, leading to death.

Blood serves as a rich medium for the growth of bacteria. Abortion is a bloody event, and if it is unsafely done, will lead to infection of the genital tract of the woman. This infection can travel into the womb, into the fallopian tubes or ovi ducts, and into the pelvic cavity and the peritoneum. This can result in a serious infection that can 'poison' the whole blood of the woman, and lead to death. For those who don't die, a chronic pelvic inflammatory disease may result, which can cause the woman to have lower abdominal pains and vaginal discharges for the rest of her life. This infection can also destroy the fallopian tubes and lead to ectopic (abnormally placed) pregnancies, and even lead to infertility.

Where sharp objects are used to induce abortion, lack of knowledge on the part of the person conducting the procedure may lead to perforation of the uterus and damage to the small and large intestines or urinary bladder. If any of these damages occur during an unsafe abortion, the woman would need a laparotomy (opening of the abdomen) to look for and correct the damage or harm done, otherwise she will die. There have been situations where desperate attempts to abort a pregnancy by an unqualified person had resulted in serious damage to the vagina and cervix of some women, rendering them incapable of having babies or delivering babies by themselves ever again.

Where concoctions are drunk or inserted into the vagina, cervix, or rectum, the effect will depend on the active components of the concoctions taken. Cytotec, for example, if abused, causes over stimulation of the uterus to contract, and may cause it to rupture leading to internal bleeding and death. Other concoctions have caused generalised poisoning and death. Some cause increased blood pulse and pressure, worsening of asthma, damage to the stomach and intestine, and so on.

Other immeasurable consequences of unsafe abortion include loss of productivity and psychological damage.   When the mother is sick, the family, community, and nation lose her services and contribution for some time. They also spend time, resource and cash on her as well. If she died, then the family, community, and nation would lose. If she had children already, their care would become a complex issue, as our social welfare system is not effective. The mental and psychological trauma of going through an unsafe abortion cannot be over emphasised, much less if the secret gets into the community.

The burden of unsafe abortion lies not only with the women and families, but also with the public health system. Every woman admitted for emergency post-abortion care may require blood and blood products, drugs, anaesthesia, operating rooms, hospital stay, and surgical specialists. The financial and logistic impact of emergency care can overwhelm a health system, and can prevent attention to be administered to other patients.

Why do women choose unsafe abortion?
The occurrence of unintended or unwanted pregnancies obviously leads to abortions, and unsafe abortions, for that matter. Lack of knowledge of contraceptive methods, poor access to contraceptive methods, improper choice and use of contraceptive methods and products may be cited for the occurrence of unwanted and unintended pregnancies. Once a woman decides, for whatever reason, to terminate her unwanted pregnancy, she will do so by whatever means necessary. Since safe abortion is not readily available, then unsafe abortion thrives. A desperate woman will not mind spending a life's fortune on getting rid of an unwanted pregnancy, or even putting her life on the line, with or without the knowledge of the consequences to do so.

The legal status of abortion plays a major role in the frequency of unsafe abortion.   For example, the 1996 legalisation of abortion in   South Africa   had an immediate positive impact on the frequency of abortion-related complications, with abortion-related deaths dropping by more than 90%. The law in Ghana allows abortion only under a few conditions such as an incest pregnancy, impregnation of an idiot mother, impregnated rape victim, or when health care workers determine that the baby, if born, will not be able to have a meaningful life, or if the pregnancy threatens the health or life of the mother, should she continue with the pregnancy. The laws of Ghana do not allow a healthy mother with a healthy pregnancy to get an abortion with the sole reason of not wanting the pregnancy. This law criminalising safe abortion leads women to seek unsafe abortion, leading to increased unwarranted maternal deaths and morbidities.

Our socio-cultural set up also pushes women to seek unsafe abortions. Every tribe and traditional area in Ghana frowns on issues of abortion, and will condemn it, no matter the reason for it. Christianity and Islam also frown on abortions. These faiths also do not promote the much needed sex education and education on contraceptive methods which can empower their believers to prevent unwanted and unintended pregnancies. So, when these pregnancies occur, the women involved clandestinely seek abortion from the 'black market', where unsafe abortion is offered. These abortions result in complications, and because of the disgrace the woman and her family may be exposed to, should they be found out, she and the family may not report such complications to the hospital, or may do so late, resulting in unnecessary maternal deaths.
Way forward
The World Health Organisation deems unsafe abortions one of the easiest preventable causes of maternal morbidity and mortality. As the saying goes, 'prevention is better than cure'. Preventing unintended pregnancy should be a priority for all nations. Educating women, regarding their reproductive health, should be incorporated in the schools' curricula.   We need to increase contraceptive services, and make it accessible and readily available. This should include providing accurate information on choices and proper use of contraceptive methods. Governments and non-governmental organisations need to find effective ways to overcome cultural and social misconceptions that restrict women from receiving the necessary reproductive health care.

Where ever in this world that the laws are liberal on abortion, unsafe abortion is drastically reduced. That is a fact. The law on abortion in Ghana is restrictive and must be liberalised further.   The emotional, physiologic, psychological and financial costs on women and families, as well as the burden on the economic health system, as a result of unsafe abortions, must be weighed against appearing nice and holy in our law books. Liberalising abortion laws does not mean abortion can now be used as a contraceptive method. It will save lots of women, and improve their reproductive health.

Health practitioners need to become better trained in safer abortion methods, and be able to transfer patients to a medical facility that is capable of providing emergency care when a complication arises. WHO strongly advises that all health facilities that treat women with incomplete abortions have the appropriate equipment and trained staff needed to ensure that care is consistently available and provided at a reasonable cost. In addition, post-abortion family planning counselling needs to be an integral part of the service.

By Dr Emmanuel K. Coomson, Takoradi Hospital

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