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Abortion complications in abidjan (Ivory Coast)
ORIGINAL RESEARCH ARTICLE
Abortion Complications in Abidjan (Ivory Coast) Nathalie Goyaux,* Fre´de´rique Yace´-Soumah,† Christiane Welffens-Ekra,† and Patrick Thonneau* The aim of this study was to describe the various methods of abortion used by women admitted to an obstetrics department in Abidjan (Ivory Coast) for abortion complications. The study was retrospective, and was based on the medical files of all 472 women admitted for abortion complications during a 3-year period (1993–1995). The introduction of plant stems into the uterus, the use of certain instruments, use of vaginal preparations, and ingestion of plants were the most common abortion methods. Seventeen maternal deaths were registered, giving a maternal mortality rate of 3.6%. A high number of previous pregnancies and the ingestion of plants to provoke abortion were factors associated with the highest risk for maternal death. Complications of “local” abortion methods accounted for a high proportion of maternal deaths. CONTRACEPTION 1999;60:107–109 © 1999 Elsevier Science Inc. All rights reserved. KEY WORDS:
maternal morbidity and mortality, methods of induced abortion
Introduction
I
n developing countries, particularly those of West Africa, there is a high risk of death during pregnancy, childbirth, or within the 42 days immediately after the end of pregnancy. Recent statistics from the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF)1 show that the maternal mortality rate (expressed as the number of maternal deaths per 100,000 live births) in such regions is 200 to 300 per 100,000 births in urban areas and 400 to 700 per 100,000 births in rural areas. A study conducted by Thonneau et al.2 in an obstetrics department in Abidjan reported a maternal mortality rate of 240 per 100,000 live births in 1995. *Institut National de la Sante´ et de la Recherche Me´dicale, Human Fertility Research Group, La Grave Hospital, Toulouse Cedex, France; and †Gynecology and Obstetrics Department, Centre Hospitalier Universitaire of Yopougon, Abidjan, Ivory Coast Name and address for correspondence: Dr. Patrick Thonneau, Hoˆpital La Grave, Service d’Urologie et Andrologie, Groupe de Recherche en Fertilite´ Humaine, 31052 Toulouse Cedex, France; Tel.: 33 5 61 77 80 35; Fax: 33 5 61 77 78 34; e-mail: [email protected] Submitted for publication July 1, 1999 Revised August 10, 1999 Accepted for publication August 16, 1999
© 1999 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
Higher rates of maternal mortality have been reported in Guinea, particularly in rural regions, with 800 maternal deaths per 100,000 live births.3 In West African countries, where abortion is illegal, Rogo4 suggested that complications of induced abortions account for about one-third of all maternal deaths. Many women who do not wish to continue their pregnancy are forced to undergo clandestine abortion. Thus, as shown by Linskin,5 a large number of abortions are carried out using “local” methods, and this results in very high rates of maternal morbidity and mortality. An exhaustive review by Bleek and Asante-Darko6 found that indigenous plants were the principal means of abortion in Ghana and that the use of plant twigs was associated with particularly high rates of maternal mortality. These methods of abortion are very widespread and are familiar to health care professionals, but there have been few studies of their consequences in terms of maternal morbidity and mortality. We carried out a retrospective study of women admitted to a large obstetrics department in Abidjan (Yopougon University Hospital), to assess the effect of various abortion practices on maternal health.
Methods A list was made of all abortion cases admitted to the obstetrics department of Yopougon University Hospital between January 1, 1993, and December 31, 1995 (3 years). The sociodemographic and medical characteristics of the women, and whether the women were alive or dead on admission, were extracted from the medical files and used by specially trained researchers to complete a questionnaire. If it was difficult to establish a diagnosis, particularly to differentiate between miscarriages and induced abortion, the obstetric department’s staff carried out a reevaluation. The duration of amenorrhea before the abortion was calculated based on the date of the last period and was classified as ⱕ15 weeks versus ⱖ16 weeks. The various methods used to perform the abortions were listed and described as faithfully as possible. We also ISSN 0010-7824/99/$20.00 PII S0010-7824(99)00070-0
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Contraception 1999;60:107–109
Table 1. Odds ratio and confidence intervals for maternal deaths Dead
Alive
n
%
n
%
OR*
95% CI
OR†
95% CI
Age, years ⬍20 20–29 ⬎30
2 9 5
13 56 31
161 237 50
36 53 11
1.0 3.1 8.1
0.6–20.8 1.3–62.0
No. of pregnancies ⱕ4 ⱖ5
5 6
46 54
357 77
82 18
1.0 5.6
1.7–18.7
1.0 6.2
1.6–24.0
Duration of amenorrhea ⱕ15 weeks ⱖ16
8 5
62 38
350 64
85 15
1.0 3.4
1.1–10.8
1.0 3.7
1.0–14.2
Plant infusion No Yes
9 8
53 47
371 84
81 19
1.0 3.9
1.3–11.5
1.0 6.1
1.5–24.9
Twig insertion No Yes
15 2
88 12
425 30
93 7
1.0 1.9
0.1–9.3
1.0 2.8
0.3–27.7
* Unadjusted estimates † Adjusted estimates (logistic regression analysis)
identified some severe complications (peritonitis and neurological disorders) from the medical files. The data collected by the questionnaire were entered into the computer using the EPI-Info program and were analyzed with SPSS (Chicago, IL) software, using the 2 test, and odds ratio (OR) with 95% confidence interval (CI). We also performed a multivariate logistic regression to estimate the various risk factors for maternal death (adjusted OR).
Results Between 1993 and 1995, 472 women (study population) were admitted because of abortion complications (ie, 8% of the 6103 women admitted to the obstetrics department over the same period). In the study population, the mean age of the women was 22.5 years (SD 5.4 years). Of these, 35% were ⬍20 years old, 53% were between 20 and 30 years, and 12% were ⱖ30 years; 23% were still at school or were students. The women had a mean of 2.3 (SD ⫾ 1.8) children at the time of the abortion. The present abortion was for a first pregnancy in 27% of the women, and 19% said they had had five or more previous pregnancies. Of the women, 49% were pregnant for ⬍10 weeks, 36% for 10 –15 weeks, and 15% for ⱖ16 weeks. Of the 472 women admitted, 40 (9%) had signs of peritonitis, which was significantly (p ⬍0.001) associated with intrauterine methods, and 28 (6%) presented with signs of neurological disorders that were strongly correlated with the use of plant infusions (p ⬍10⫺5).
Data on the various abortion methods used were available in 99% (467 of 472) of the women. Examination of medical records showed that only 7% (33 of 467) of the women had used two or more methods in combination. For the 434 women who had used only one method, intrauterine methods (eg, insertion of a twig into the uterus and the use of instruments; 31%) were the most frequently used, followed by herbal pessary (23%), and plant infusions (20%). Table 1 shows the death risk for the women who used one method only. There were 17 maternal deaths (3.6%) among the 472 women admitted for abortion complications over the 3 years of this study. Deaths due to abortion complications accounted for 17 of the 32 maternal deaths registered in the obstetrics department of Yopougon over the study period. Many of the abortion complication–related deaths occurred in women who had carried out abortions using plant infusions (eight of 17). Table 1 indicates the risk, given as OR, of maternal death in univariate and multivariate analysis. Table 1 shows that the risk of maternal death (unadjusted estimates) was significantly associated with increasing age (p ⬍0.05), a duration of amenorrhea of ⱖ16 weeks (p ⬍0.05), a large number of previous pregnancies (five or more) (p ⬍0.01), and the use of plant infusions (p ⬍0.01). The logistic regression analysis (including all the significant variables) (SPSS) indicates that a large number of previous pregnancies (OR, 6.2; 95% CI, 1.6 –24.0) and the use of plant
Contraception 1999;60:107–109
infusions (OR, 6.1; 95% CI, 1.5–24.9) were the factors with the highest risk for maternal death.
Discussion In this study, the frequency of maternal death due to abortion complications was very high: 17 of the 472 women (3.6%) died. Deaths related to abortion complications accounted for more than half of all maternal deaths in this obstetrics department. Similar results were reported in a study carried out between 1992 and 1994 on all the health facilities of Abidjan.2 There are a number of possible reasons for such high mortality rates associated with abortion. First, the illegality of abortion in the Ivory Coast, as in most African countries, leads many women who do not wish to continue their pregnancy to resort to “local” abortion methods. These methods are not as effective and are much more dangerous than the surgical techniques used in industrialized countries (vacuum aspiration). Consequently, these methods frequently give rise to complications, which are often serious. In addition, as shown by Diadhiou et al,7 in a society in which abortion is not permitted and medical care is expensive, women initially conceal abortion complications, seeking medical help only as a last resort. We also know that the hospital management of gynecological emergencies is often late and inappropriate and that these women are often prejudged by health care staff.8 In a study conducted in Zambia, where abortion is legal, Koster-Oyekan9 found that most women resort to “local” abortion methods because legal abortion services are inaccessible and unacceptable. Finally, the low prevalence of contraception in the urban agglomeration of Abidjan (10% in 1996) presumably also results in a high number of unwanted pregnancies, leading to numerous illegal abortions using such “local” methods. In our study, plant infusions were associated with major neurological disorders and were responsible for the largest number of maternal deaths (eight of 17). As reported by Bleek and Asante-Darko,6 indigenous local plants made up the largest group of abortifacients in West Africa. These local plants may be applied in many different ways: mechanically, by inserting a twig into the uterus; as a drink; after grinding (plants, leaves, or roots) and mixing with
Abortion Complications
109
other ingredients (sugar, medicines, alcohol). The serious complications of these abortion methods may be partly due to synergy between the plants and other adjuvants frequently used (ie, salicylates, chloroquine, ergometrine, oxytocin). Some abortion complications were probably omitted from medical records either because of errors in diagnosis (confusion with miscarriage) or at the specific request of the woman or her family. The retrospective approach used in this study also limited the information available, particularly the reproductive history of the women, which was not given in the medical files. In conclusion, we found that the potential lethal risks associated with “local” abortion methods were high. These results suggest that more rapid and efficient hospitalization in abortion cases and greater access to family planning would reduce the rate of maternal mortality in the Ivory Coast.
References 1. Revised estimates of maternal mortality, a new approach by WHO and UNICEF. Geneva, New York: World Health Organization and United Nations Children’s Fund, 1996. 2. Thonneau P, Djanhan Y, Tran M, Welffens-Ekra C, Bohoussou M, Papiernik E. The persistence of a high maternal mortality rate in the Ivory Coast. Am J Pub Health 1996;86:1478 –9. 3. Toure´ B, Thonneau P, Cantrelle P, Barry TM, Ngo-Khac T, Papiernik E. Level and causes of maternal mortality in Guinea (West Africa). Int J Gynecol Obstet 1992;37: 89 –95. 4. Rogo KO. Induced abortion in Sub-Saharan Africa. East Afr Med J 1993;70:386 –95. 5. Linskin LS. Maternal morbidity in developing countries: a review and comments. Int J Gynecol Obstet 1992;37:77– 87. 6. Bleek W, Asante-Darko NK. Illegal abortion in Southern Ghana: methods, motives and consequences. Hum Organ 1986;45:333– 44. 7. Diadhiou F, Goyaux N, Faye O, Thonneau P. A neglected but prevalent tragedy. Br Med J 1999;318:1526. 8. Faundes A, Hardy E. Illegal abortion: consequences for women’s health and the health care system. Int J Gynecol Obstet 1997;58:77– 83. 9. Koster-Oyekan W. Why resort to illegal abortion in Zambia? Findings of a community-based study in Western Province. Soc Sci Med 1998;46:1303–12.
Abortion Complications in Abidjan (Ivory Coast) Nathalie Goyaux,* Fre´de´rique Yace´-Soumah,† Christiane Welffens-Ekra,† and Patrick Thonneau* The aim of this study was to describe the various methods of abortion used by women admitted to an obstetrics department in Abidjan (Ivory Coast) for abortion complications. The study was retrospective, and was based on the medical files of all 472 women admitted for abortion complications during a 3-year period (1993–1995). The introduction of plant stems into the uterus, the use of certain instruments, use of vaginal preparations, and ingestion of plants were the most common abortion methods. Seventeen maternal deaths were registered, giving a maternal mortality rate of 3.6%. A high number of previous pregnancies and the ingestion of plants to provoke abortion were factors associated with the highest risk for maternal death. Complications of “local” abortion methods accounted for a high proportion of maternal deaths. CONTRACEPTION 1999;60:107–109 © 1999 Elsevier Science Inc. All rights reserved. KEY WORDS:
maternal morbidity and mortality, methods of induced abortion
Introduction
I
n developing countries, particularly those of West Africa, there is a high risk of death during pregnancy, childbirth, or within the 42 days immediately after the end of pregnancy. Recent statistics from the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF)1 show that the maternal mortality rate (expressed as the number of maternal deaths per 100,000 live births) in such regions is 200 to 300 per 100,000 births in urban areas and 400 to 700 per 100,000 births in rural areas. A study conducted by Thonneau et al.2 in an obstetrics department in Abidjan reported a maternal mortality rate of 240 per 100,000 live births in 1995. *Institut National de la Sante´ et de la Recherche Me´dicale, Human Fertility Research Group, La Grave Hospital, Toulouse Cedex, France; and †Gynecology and Obstetrics Department, Centre Hospitalier Universitaire of Yopougon, Abidjan, Ivory Coast Name and address for correspondence: Dr. Patrick Thonneau, Hoˆpital La Grave, Service d’Urologie et Andrologie, Groupe de Recherche en Fertilite´ Humaine, 31052 Toulouse Cedex, France; Tel.: 33 5 61 77 80 35; Fax: 33 5 61 77 78 34; e-mail: [email protected] Submitted for publication July 1, 1999 Revised August 10, 1999 Accepted for publication August 16, 1999
© 1999 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
Higher rates of maternal mortality have been reported in Guinea, particularly in rural regions, with 800 maternal deaths per 100,000 live births.3 In West African countries, where abortion is illegal, Rogo4 suggested that complications of induced abortions account for about one-third of all maternal deaths. Many women who do not wish to continue their pregnancy are forced to undergo clandestine abortion. Thus, as shown by Linskin,5 a large number of abortions are carried out using “local” methods, and this results in very high rates of maternal morbidity and mortality. An exhaustive review by Bleek and Asante-Darko6 found that indigenous plants were the principal means of abortion in Ghana and that the use of plant twigs was associated with particularly high rates of maternal mortality. These methods of abortion are very widespread and are familiar to health care professionals, but there have been few studies of their consequences in terms of maternal morbidity and mortality. We carried out a retrospective study of women admitted to a large obstetrics department in Abidjan (Yopougon University Hospital), to assess the effect of various abortion practices on maternal health.
Methods A list was made of all abortion cases admitted to the obstetrics department of Yopougon University Hospital between January 1, 1993, and December 31, 1995 (3 years). The sociodemographic and medical characteristics of the women, and whether the women were alive or dead on admission, were extracted from the medical files and used by specially trained researchers to complete a questionnaire. If it was difficult to establish a diagnosis, particularly to differentiate between miscarriages and induced abortion, the obstetric department’s staff carried out a reevaluation. The duration of amenorrhea before the abortion was calculated based on the date of the last period and was classified as ⱕ15 weeks versus ⱖ16 weeks. The various methods used to perform the abortions were listed and described as faithfully as possible. We also ISSN 0010-7824/99/$20.00 PII S0010-7824(99)00070-0
108
Goyaux et al.
Contraception 1999;60:107–109
Table 1. Odds ratio and confidence intervals for maternal deaths Dead
Alive
n
%
n
%
OR*
95% CI
OR†
95% CI
Age, years ⬍20 20–29 ⬎30
2 9 5
13 56 31
161 237 50
36 53 11
1.0 3.1 8.1
0.6–20.8 1.3–62.0
No. of pregnancies ⱕ4 ⱖ5
5 6
46 54
357 77
82 18
1.0 5.6
1.7–18.7
1.0 6.2
1.6–24.0
Duration of amenorrhea ⱕ15 weeks ⱖ16
8 5
62 38
350 64
85 15
1.0 3.4
1.1–10.8
1.0 3.7
1.0–14.2
Plant infusion No Yes
9 8
53 47
371 84
81 19
1.0 3.9
1.3–11.5
1.0 6.1
1.5–24.9
Twig insertion No Yes
15 2
88 12
425 30
93 7
1.0 1.9
0.1–9.3
1.0 2.8
0.3–27.7
* Unadjusted estimates † Adjusted estimates (logistic regression analysis)
identified some severe complications (peritonitis and neurological disorders) from the medical files. The data collected by the questionnaire were entered into the computer using the EPI-Info program and were analyzed with SPSS (Chicago, IL) software, using the 2 test, and odds ratio (OR) with 95% confidence interval (CI). We also performed a multivariate logistic regression to estimate the various risk factors for maternal death (adjusted OR).
Results Between 1993 and 1995, 472 women (study population) were admitted because of abortion complications (ie, 8% of the 6103 women admitted to the obstetrics department over the same period). In the study population, the mean age of the women was 22.5 years (SD 5.4 years). Of these, 35% were ⬍20 years old, 53% were between 20 and 30 years, and 12% were ⱖ30 years; 23% were still at school or were students. The women had a mean of 2.3 (SD ⫾ 1.8) children at the time of the abortion. The present abortion was for a first pregnancy in 27% of the women, and 19% said they had had five or more previous pregnancies. Of the women, 49% were pregnant for ⬍10 weeks, 36% for 10 –15 weeks, and 15% for ⱖ16 weeks. Of the 472 women admitted, 40 (9%) had signs of peritonitis, which was significantly (p ⬍0.001) associated with intrauterine methods, and 28 (6%) presented with signs of neurological disorders that were strongly correlated with the use of plant infusions (p ⬍10⫺5).
Data on the various abortion methods used were available in 99% (467 of 472) of the women. Examination of medical records showed that only 7% (33 of 467) of the women had used two or more methods in combination. For the 434 women who had used only one method, intrauterine methods (eg, insertion of a twig into the uterus and the use of instruments; 31%) were the most frequently used, followed by herbal pessary (23%), and plant infusions (20%). Table 1 shows the death risk for the women who used one method only. There were 17 maternal deaths (3.6%) among the 472 women admitted for abortion complications over the 3 years of this study. Deaths due to abortion complications accounted for 17 of the 32 maternal deaths registered in the obstetrics department of Yopougon over the study period. Many of the abortion complication–related deaths occurred in women who had carried out abortions using plant infusions (eight of 17). Table 1 indicates the risk, given as OR, of maternal death in univariate and multivariate analysis. Table 1 shows that the risk of maternal death (unadjusted estimates) was significantly associated with increasing age (p ⬍0.05), a duration of amenorrhea of ⱖ16 weeks (p ⬍0.05), a large number of previous pregnancies (five or more) (p ⬍0.01), and the use of plant infusions (p ⬍0.01). The logistic regression analysis (including all the significant variables) (SPSS) indicates that a large number of previous pregnancies (OR, 6.2; 95% CI, 1.6 –24.0) and the use of plant
Contraception 1999;60:107–109
infusions (OR, 6.1; 95% CI, 1.5–24.9) were the factors with the highest risk for maternal death.
Discussion In this study, the frequency of maternal death due to abortion complications was very high: 17 of the 472 women (3.6%) died. Deaths related to abortion complications accounted for more than half of all maternal deaths in this obstetrics department. Similar results were reported in a study carried out between 1992 and 1994 on all the health facilities of Abidjan.2 There are a number of possible reasons for such high mortality rates associated with abortion. First, the illegality of abortion in the Ivory Coast, as in most African countries, leads many women who do not wish to continue their pregnancy to resort to “local” abortion methods. These methods are not as effective and are much more dangerous than the surgical techniques used in industrialized countries (vacuum aspiration). Consequently, these methods frequently give rise to complications, which are often serious. In addition, as shown by Diadhiou et al,7 in a society in which abortion is not permitted and medical care is expensive, women initially conceal abortion complications, seeking medical help only as a last resort. We also know that the hospital management of gynecological emergencies is often late and inappropriate and that these women are often prejudged by health care staff.8 In a study conducted in Zambia, where abortion is legal, Koster-Oyekan9 found that most women resort to “local” abortion methods because legal abortion services are inaccessible and unacceptable. Finally, the low prevalence of contraception in the urban agglomeration of Abidjan (10% in 1996) presumably also results in a high number of unwanted pregnancies, leading to numerous illegal abortions using such “local” methods. In our study, plant infusions were associated with major neurological disorders and were responsible for the largest number of maternal deaths (eight of 17). As reported by Bleek and Asante-Darko,6 indigenous local plants made up the largest group of abortifacients in West Africa. These local plants may be applied in many different ways: mechanically, by inserting a twig into the uterus; as a drink; after grinding (plants, leaves, or roots) and mixing with
Abortion Complications
109
other ingredients (sugar, medicines, alcohol). The serious complications of these abortion methods may be partly due to synergy between the plants and other adjuvants frequently used (ie, salicylates, chloroquine, ergometrine, oxytocin). Some abortion complications were probably omitted from medical records either because of errors in diagnosis (confusion with miscarriage) or at the specific request of the woman or her family. The retrospective approach used in this study also limited the information available, particularly the reproductive history of the women, which was not given in the medical files. In conclusion, we found that the potential lethal risks associated with “local” abortion methods were high. These results suggest that more rapid and efficient hospitalization in abortion cases and greater access to family planning would reduce the rate of maternal mortality in the Ivory Coast.
References 1. Revised estimates of maternal mortality, a new approach by WHO and UNICEF. Geneva, New York: World Health Organization and United Nations Children’s Fund, 1996. 2. Thonneau P, Djanhan Y, Tran M, Welffens-Ekra C, Bohoussou M, Papiernik E. The persistence of a high maternal mortality rate in the Ivory Coast. Am J Pub Health 1996;86:1478 –9. 3. Toure´ B, Thonneau P, Cantrelle P, Barry TM, Ngo-Khac T, Papiernik E. Level and causes of maternal mortality in Guinea (West Africa). Int J Gynecol Obstet 1992;37: 89 –95. 4. Rogo KO. Induced abortion in Sub-Saharan Africa. East Afr Med J 1993;70:386 –95. 5. Linskin LS. Maternal morbidity in developing countries: a review and comments. Int J Gynecol Obstet 1992;37:77– 87. 6. Bleek W, Asante-Darko NK. Illegal abortion in Southern Ghana: methods, motives and consequences. Hum Organ 1986;45:333– 44. 7. Diadhiou F, Goyaux N, Faye O, Thonneau P. A neglected but prevalent tragedy. Br Med J 1999;318:1526. 8. Faundes A, Hardy E. Illegal abortion: consequences for women’s health and the health care system. Int J Gynecol Obstet 1997;58:77– 83. 9. Koster-Oyekan W. Why resort to illegal abortion in Zambia? Findings of a community-based study in Western Province. Soc Sci Med 1998;46:1303–12.