Maternal mortality and unsafe abortion

Best Practice & Research Clinical Obstetrics and Gynaecology Vol. 22, No. 3, pp. 533–548, 2008 doi:10.1016/j.bpobgyn.2007.10.006 available online at http://www.sciencedirect.com

8 Maternal mortality and unsafe abortion Susan R. Fawcus *

MA (Oxon.), MBBCH, FRCOG

Associate Professor Department of Obstetrics and Gynaecology, University of Cape Town, South Africa

Unsafe abortions refer to terminations of unintended pregnancies by persons lacking the necessary skills, or in an environment lacking the minimum medical standards, or both. Globally, unsafe abortions account for 67,900 maternal deaths annually (13% of total maternal mortality) and contribute to significant morbidity among women, especially in under-resourced settings. The determinants of unsafe abortion include restrictive abortion legislation, lack of female empowerment, poor social support, inadequate contraceptive services and poor health-service infrastructure. Deaths from unsafe abortion are preventable by addressing the above determinants and by the provision of safe, accessible abortion care. This includes safe medical or surgical methods for termination of pregnancy and management of incomplete abortion by skilled personnel. The service must also include provision of emergency medical or surgical care in women with severe abortion complications. Developing appropriate services at the primary level of care with a functioning referral system and the inclusion of post abortion contraceptive care with counseling are essential facets of abortion care. Key words: abortion legislation; contraception; manual vacuum aspiration; maternal mortality; postabortion care; unintended pregnancy; unsafe abortion.

INTRODUCTION It is estimated that – globally – unsafe abortions are responsible for 67,900 maternal deaths annually, accounting for 13% of total maternal mortality.1 The marked disparities between countries in abortion-related mortality are associated with differences in abortion legislation, dominant religion, socioeconomic status, contraceptive coverage, and the availability of accessible effective comprehensive abortion care services. The most common mode of death is septic shock with multiorgan failure, with or without haemorrhage. These deaths are preventable and represent a tragic unnecessary loss of women’s lives.2 * Mowbray Maternity Hospital, P/Bag Mowbray, Cape Town 7705, South Africa. E-mail address: [email protected] 1521-6934/$ - see front matter ª 2007 Elsevier Ltd. All rights reserved.

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DEFINITIONS AND TERMINOLOGY Unsafe abortion: a procedure ‘‘characterized by the lack or inadequacy of skills of the provider, hazardous techniques and unsanitary facilities’’.3 This definition was formulated by a World Health Organization (WHO) technical working group in 1992 with the aim of directing the focus to the safety of the abortion procedure rather than the legality or whether it was induced. It thus covers pregnancies terminated by unskilled personnel or self-induced that have adverse sequelae, both in countries with restrictive abortion legislation and also in those with enabling legislation but limited availability of functioning facilities to provide the service. It would also include spontaneous miscarriages in which sepsis or other complications have developed. The term ‘‘unsafe abortion’’ is preferable to previous terminology: terms such as ‘‘back street abortion’’, ‘‘illegal abortion’’ and ‘‘criminal abortion’’ have all been used; they have judgmental inferences and are difficult to measure accurately. Also, in some circumstances, abortions performed ‘‘illegally’ in countries with restrictive legislation can be performed safely with no adverse sequelae. Miscarriage and termination of pregnancy (TOP): a miscarriage refers to a spontaneous pregnancy loss before 22 completed weeks or of a fetus weighing less than 500 g. This term is preferred (rather than ‘‘abortion’’) for pregnancy loss that is not induced.4 In countries where pregnancies can be and are terminated legally, the term ‘‘termination of pregnancy’’ is used to refer to induced abortion. In countries with restrictive abortion legislation, a woman admitted with an incomplete miscarriage is unlikely to divulge to the health worker as to whether it was really induced, making it difficult to know if an admission for incomplete abortion is a spontaneous miscarriage or self-procured termination of pregnancy. This is why it is still necessary to retain the term ‘‘unsafe abortion’’ for these situations. Unsafe abortion incidence rate: the number of unsafe abortions per 1000 women in the reproductive age group (15–49) per year.1 Unsafe abortion incidence ratio: the number of unsafe abortions per 100 live births.1 Unsafe abortion mortality ratio: total number of maternal deaths due to unsafe abortion per 100,000 live births.1 Abortion-related deaths would be classified as direct maternal deaths. Unsafe abortion case fatality rate: the number of deaths due to unsafe abortion expressed as a percentage of the total number unsafe abortion procedures.1 UNSAFE ABORTION It is estimated that, of the 210 million women who become pregnant each year, 80 million have unintended pregnancies. Of these, 46 million are terminated voluntarily: 27 million legally and 19 million outside the legal system.5 Criteria for describing abortions as ‘unsafe’ The South African National Incomplete Abortion Study, conducted in 1994, developed an abortion morbidity classification system (Table 1). This is a useful tool for identifying an abortion as unsafe.6 It was an elaboration of previous attempts by WHO and other researchers to categorize the morbidity of abortion admissions.7,8 Using this classification, the study, which was conducted in 56 public-sector South African hospitals in 1996, investigated 803 women admitted with incomplete abortions. Of these, 15% had severe and 19% moderate morbidity, indicating that 34% of these

Maternal mortality and unsafe abortion 535

Table 1. Unsafe abortion defined by morbidity severity categories. Severity categories Low

Moderate

High

Definition Temperature  37.2  C No clinical signs of infection No system or organ failure No suspicious findings on evacuation Temperature 37.3e37.9  C Offensive products Localized peritonitis Temperature  38  C Organ failure Peritonitis Pulse  120 Death Foreign body/mechanical injury on evacuation

and and and or or or or or or or

hospital admissions were for unsafe abortions. This approach was subsequently used in Kenya, where it was found that 44.2% of emergency abortion admissions were unsafe.9 Spontaneous first-trimester miscarriage is more common than second trimester, the latter accounting for less than 20% of spontaneous miscarriages. In countries with high rates of unsafe abortion, second-trimester abortions might account for nearly 40% of emergency admissions suggesting that they are not spontaneous.6,9 Epidemiology of unsafe abortion There is paucity of accurate statistics on the incidence of unsafe abortion, particularly in under-resourced countries with poor health information systems and in countries with restrictive laws, where such cases might not be reported if procured clandestinely. The WHO Department of Reproductive Health maintains a database on unsafe abortion and its associated mortality.1 Data is obtained from records of hospital admissions and community surveys. Whereas data might be accurate in well-resourced countries, in most under-resourced countries they are estimates only. WHO data provide the following estimates: 97% of unsafe abortions occur in under-resourced countries. The unsafe abortion incidence rate varies from 2 per 1000 women in well-resourced countries to 16 per 1000 in under-resourced countries. In Western Europe, the incidence rate is so low as to be negligible. In under-resourced countries, the incidence rate varies from 31 per 1000 women in East Africa and 34 per 1000 in South America to a negligible figure in Eastern Asia, where unsafe abortion is very rare. The same report suggests that there was a decline in the unsafe abortion incidence rate from 1995–2000 in Central America, the Caribbean and Middle, Eastern and Western Africa. A study compiling hospital admissions for abortion complications from 13 underresourced countries showed annual hospitalization rates as low as 3 per 1000 women in Bangladesh, about 9 per 1000 in Latin America and 15 per 1000 in Egypt and Uganda.10 Such figures give some indication of the magnitude of the problem, but do not reflect it accurately as many women will never access hospital. In Africa, teenagers account for a large percentage of women with unsafe abortion; 60% of unsafe abortions are in women less than 25 years old, as compared to 30% in

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Asia. There is particular concern about the increasing numbers of unsafe abortions in 15- to 19-year-olds in Africa.2 Background determinants of unsafe abortion These can be divided into the reasons for unintended unwanted pregnancy and the reasons why the abortion was unsafe. Reasons for unintended and unwanted pregnancy These are many: financial hardship, lack of social support, desertion by partner, sexual abuse, interference with studies/training, and contraceptive failure or non-availability.2 A qualitative study of Nigerian adolescents indicated that many seeking abortion had not been motivated to use contraception.11 A case-control study in Zimbabwe identified lack of social support as an important factor.12 Globally, it is estimated that 120 million couples have an unmet need for contraception, particularly in under-resourced countries.5 Contraceptive services are not always readily accessible for the young teenager or the older women (over 40years).13 The decision to terminate can be viewed as a desperate but often responsible decision not to pursue a pregnancy when the social and economic circumstances are not favorable. This includes, particularly in Asia and Latin America, married women with children who cannot cope financially with another pregnancy. In Africa, there is a disturbing increase in nulliparous teenagers procuring abortions. Interestingly, in countries with high rates of unsafe abortion there is a positive correlation with increasing education, the least educated women in rural areas being less likely to pursue induced abortion.14 High levels of violence against women remain a major problem in many societies. In some well-resourced countries, such as the UK, there is also concern about the increasing number of teenage pregnancies and qualitative research directed at ascertaining underlying circumstances suggesting that in some cases there might be a subconscious motivation for pregnancy. Reasons the abortion was unsafe When unintended pregnancy leads to a decision to terminate, then the reason that the procured abortion is unsafe would be due to it being illegal and abortion providers being unskilled; or, in the context of legality, there being inadequate services, leading to delays and late presentation when the pregnancy has advanced to the second trimester, which is associated with more complications.1 In addition, provider unwillingness due to moral disagreements with TOP and the international ‘gagging’ rule, whereby some international agencies provide aid for health programs in under-resourced countries conditional on them not including abortion care programs, can further impede the development of quality abortion care services.2,15 Women’s health services are often not given priority in health service resource allocations and so services remain underdeveloped and underskilled.16 Methods of unsafe abortions Over the years, many have been described:2  Oral ingestion of herbal medications, quinine, and strong teas have all been described.11

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 Abdominal massage, which can lead to trauma.  Local methods, including douches with noxious substances, and enemas.  Twigs, knitting needles and catheters placed through the cervix, often in unsterile conditions. In the Dominican Republic, it has been suggested that the over-the-counter purchase of misoprostol, a synthetic prostaglandin, might have led to this method replacing previous, more dangerous methods, accounting for the falling incidence of unsafe abortions.17 However, unregulated use of misoprostol also has adverse sequelae; these will be discussed later. Morbidity and mortality associated with unsafe abortion Morbidity and mortality from unsafe abortion depends on the procedure used, the skill of the provider and whether the procedure is carried out using sterile techniques. In addition, the general health of the women influences her outcome, as does the gestational age of the pregnancy; second-trimester procedures being associated with greater morbidity than those in the first trimester. Another factor determining outcome is the availability and quality of medical back-up when complications arise.1 The most common morbidities associated with unsafe abortion are sepsis and haemorrhage. In addition, trauma from foreign bodies and metabolic complications associated with renal failure can arise from ingestion of chemicals for abortion. The sepsis results from a combination of retained products, trauma and non-sterile techniques. It can be compounded by late presentation at a health facility because of fear of criminal investigations. Uterine sepsis, if not treated or if treated inadequately, can lead to uterine necrosis with peritonitis, septic shock and various organ failures (paralytic ileus, disseminated intravascular coagulopathy, adult respiratory distress syndrome, liver dysfunction and renal failure). Severe haemorrhage can result in death from hypovolemic shock and coagulopathy. Trauma of the genital tract can cause death by sepsis or haemorrhage. It can result from bowel trauma from sharp objects passed through the cervix, which perforate the uterus and damage the bowel. Common organisms are Gram-negative, anaerobic, and also Gram-positive bacteria, which are part of the vaginal flora. Occasionally, clostridial infections can occur in very unsterile conditions.18 Long-term complications of survivors of severe morbidity include infertility and chronic pelvic pain. In countries where there is poor access to safe induced abortion, admissions to health facilities for septic abortion are very common and account for considerable part of the health budget.13,19,20. It is estimated that at least 67,900 women die annually from complications of unsafe abortion, the majority in Africa and Asia.1 The case fatality rate is estimated to be 367 per 100,000 unsafe abortions (0.37%), and is four times greater in under-resourced than in well-resourced countries. In different countries, the proportion of maternal deaths related to unsafe abortion varies from 1% to 49%.2 The unsafe abortion maternal mortality ratio (MMR) is estimated to be about 50 per 100,000 live births globally. In East Africa it is estimated to be 140 deaths per 100,000 live births whereas in Latin America it is 30; in Sweden, rates are so low as to be negligible. The 2000–2002 UK Confidential Enquiry into Maternal Deaths gives a legal termination of pregnancy maternal mortality rate of 0.15 per 100,000 maternities.21 Most of these data are estimates from facility-based information. A study in Mexico in which a verbal autopsy technique was used as part of a community-based survey

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indicated significant underreporting of second-trimester abortion-related deaths that were not known to the formal health system.22 The authors suggest that abortionrelated deaths are more likely to be underreported than other causes of maternal death. In countries, with a high prevalence of HIV, it might be expected that sepsis associated with abortion would be increased in both induced and spontaneous abortions. As yet there are no good data to verify this. PREVENTION OF MATERNAL MORTALITY DUE TO UNSAFE ABORTION This includes primary prevention (prevention of unintended unwanted pregnancy), secondary prevention (enabling abortion legislation and the provision of accessible safe comprehensive abortion care) and tertiary prevention (the provision of skilled emergency care for severe abortion complications). Primary prevention Health education and empowerment of women It is important that sex education for boys and girls in schools focuses on determinants of behavior, such as peer pressure, as well as on acquisition of knowledge about sexuality, safe sex practices and pregnancy.23 The current AIDS pandemic in many countries has encouraged this type of education. It is necessary to focus on empowering teenagers and young women to resist non-consensual sex, although when associated with violence or economic bribery, this becomes a problem of society not doing enough to protect vulnerable women. WHO states that unsafe sex is the second most important risk factor for death and disability in the world’s poorest population.24 It is unfortunate that sexual and reproductive health targets were not included directly in the Millennium Development Goals. The International Conference on Population and Development in Cairo in 1994, stressed the importance of sexual and reproductive rights for women and moved the focus of programs away from population control towards promoting the human and reproductive rights of women in the context of public health. Reproductive health incorporates contraception, sexually transmitted infections (STIs) and HIV, cervical screening, and safe abortion. These components should be developed in the context of promoting women’s right to education, employment and empowerment in relation to male sexuality. Obstetricians and gynecologists have a duty to act as advocates for the women for whom they care.25 In countries where abortion legislation is not restrictive, it is important that the community and women are educated about their rights within the law, and are informed by the health sector about where termination of pregnancy (TOP) services can be accessed. Contraception Effective contraception can reduce but never eliminate the need for termination of pregnancy. In countries with good uptake of contraception, there are still unintended pregnancies requiring TOP.26 This is due to contraceptive failure, particularly with barrier methods and oral contraceptive pills. It indicates the importance of adequate

Maternal mortality and unsafe abortion 539

counseling when administering a method, especially contraceptive pills stressing the reasons for failure such as diarrhea, default and antibiotics. Discussion about and provision of emergency contraception should be seen as a ‘second chance’ at pregnancy prevention and provided in addition to the regular method. However, a recent survey among women attending for antenatal care and abortion in Scotland found that, despite campaigns to promote emergency contraception, only 11.8% of those presenting for abortion had used emergency contraception and there were failures among some women who used it frequently instead of regular contraception. The authors concluded that, although emergency contraception is an important adjunct, the focus still should be on provision of effective primary methods of contraception.27 In countries with a poor uptake of contraception due to poor service provision, non-use of contraception coupled with no knowledge of or poor access to emergency contraception are important reasons for unintended pregnancy. In the South African incomplete abortion study, only 53.5% women presenting with an abortion complication had ever used contraception.6 A similar study in Kenya showed that, of women presenting with an abortion complication, only 14% had used contraception prior to the current conception and only 34% had ever used contraception.9 Although it is common, in most countries, to provide contraception to postpartum women, important groups of women might be neglected in terms of effective contraceptive provision: young teenagers, women aged over 40 years and women immediately post-abortion. More ‘youth friendly’ contraceptive services are essential. In addition, the importance of post-abortal contraception has been emphasized recently in international programs.28 In Zimbabwe, a post-abortion care study illustrated the importance of post-abortion provision of contraception in preventing future unwanted pregnancy.29 Due to the demographic transition, the introduction of contraceptive services in a country for the first time initially increases the demand for TOP, because it accompanies a rising awareness of women about choice over fertility. When services are established it will lead to a decline in the need for TOP.13 In some countries, such as the previous USSR and former Yugoslavia, abortion was legalized without concurrent improvement of Family Planning services and was associated with abortion being seen as a method of family planning.30 Secondary prevention Enabling abortion legislation A systematic assessment of the relationship between legal grounds for abortion in national laws and unsafe abortion is provided by Berer.31 The analysis is based on WHO 2000 estimates of unsafe abortion incidence and associated mortality.1 Data from 165 countries clearly demonstrate that the incidence of unsafe abortion and maternal mortality from unsafe abortion is highest in countries with restrictive abortion legislation; for example, in countries with restrictive laws, the incidence of unsafe abortion is 23 per 1000 women (15–49 years) compared to 2 per 1000 in countries with liberal laws. Also, in countries with restrictive laws, the MMR due to unsafe abortion is approximately 34 per 100,000 live births, compared with 1 or less in those with liberal laws. Sixty-one per cent of the world’s population lives in countries with laws that permit TOP for a variety of reasons. Twenty seven per cent, mostly in poor countries, live in countries with restrictive legislation, often introduced by colonial governments.

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The effects of changing the legality of abortion are well illustrated in Romania, where mortality due to unsafe abortion decreased with liberalization of the abortion law, but reversed when the law was again made restrictive by the Ceauscescu regime.1 Since 1980, at least 20 countries have increased access to legal abortion.13 There appears to be advocacy for this development in many other countries, including some in Sub-Saharan Africa.32 There is evidence to show that, as abortion is made legal, in the context of adequate contraceptive services, admissions due to unsafe or complicated abortions are reduced. Although the numbers of induced abortions increase, this is accompanied by a decrease in abortion admissions with severe morbidity. This was shown in the UK after liberalization of its law and more recently in South Africa.21,6 Unfortunately, in some countries, liberalization of abortion laws was not accompanied by a decrease in admissions for unsafe abortion or mortality. Zambia and India are such examples.33,34 In the former, bureaucratic aspects to the law in terms of consent and, in both, inadequate provision and poor quality of services within the public sector, were obstacles to adequate implementation of the law. South Africa enacted a liberal abortion law in 1996; the Choice on Termination of Pregnancy (CTOP) Act. Before the date of implementation, a task team was constituted with the aim of planning implementation, devising a management protocol that could be easily implemented at primary levels using doctors and trained midwives, identifying sites, and arranging training programs for providers.35 This prevented some of the problems that arose in Zambia after liberalization and enabled the development of TOP services in many sites. However, there is an ongoing challenge to make TOP services accessible to all women and still a sizeable fraction present with unsafe abortions procured outside of designated facilities.36 An important problem identified in South Africa was that of provider unwillingness, sometimes related to conscientious objection. Values clarification workshops were initiated to help engender the respect of health workers towards each other and their patients despite differing views on the morals of TOP. The CTOP Act clearly stipulates that all women have a right to information about TOP services and that no-one should obstruct this right. The professional associations for doctors and nurses in South Africa have stipulated that all health workers are obliged to treat a woman with an emergency admission for complicated septic abortion, however it was procured.35 Provision of comprehensive safe abortion care services This section covers both safe services for induced abortion (TOP) within a legal framework, and good quality services for women admitted with incomplete abortions. In countries with liberal laws and easy access to induced abortion, then most emergency admissions for incomplete abortion are likely to be spontaneous miscarriages. However, in countries with restrictive or poorly implemented laws, many hospital admissions of women are incomplete abortions that could have been induced, but this cause is not divulged to the health worker. It is suspected when there is associated morbidity. To provide a safe abortion service at all levels of care, using providers who are not necessarily gynecologists – such as junior doctors, general medical practitioners, and nurses – there has been an impetus to identify management methods with the least complications, for which training can be feasibly provided.37 First-trimester termination of pregnancy. In first-trimester induced abortion, the use of prostaglandins to prime the cervix prior to surgical evacuation prevents difficult

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cervical dilatation and has been demonstrated in several studies to be effective.38 In addition, suction evacuation of uterine contents has replaced sharp curettage as the method of choice due to perceived advantages in speed, comfort and safety. A recent Cochrane review identified only three trials of adequate quality to compare vacuum aspiration with sharp curettage for surgical termination of first-trimester pregnancy.39 The review confirmed that vacuum aspiration has a significantly shorter procedure time, but found a similar efficacy and side-effect profile. Misoprostol as a cheap form of prostaglandin, and the hand-held manual vacuum aspiration syringe, are both affordable technologies in poor countries, and can be performed at all levels of care. They are possibly a contributing factor to the successful implementation of South Africa’s CTOP Act, where they form part of the national protocol.35 In early first-trimester TOPs (gestation less than 7 weeks), medical management alone is adequate, using a combination of mifepristone and misoprostol.40 Back-up facilities for ultrasound to confirm that the uterus is empty, and access to follow-up, is important. Medical methods are popular and acceptable to women in well-resourced countries. In under-resourced countries, their use might be limited by non-availability of mifepristone and ultrasound facilities, and the fact that few women present for TOP before 8 weeks, which is the preferred time for medical termination. In some countries with restrictive abortion legislation, there is evidence of self-use of misoprostol, and women then present to facilities with an incomplete abortion. Extensive use of misoprostol has been reported in Brazil, Guatemala and the Dominican Republic. In the last, it is thought to be the reason why hospital admissions for abortion are associated with less morbidity.17 Although procured outside the law, misoprostol is a less dangerous form of self-induced abortion than previously used methods, such as sharp objects or chemical douches. However, it is still necessary to regulate the use of misoprostol and it should not be an over-the-counter medication. If given clandestinely to procure abortion for a woman who has a pregnancy more advanced in gestation than is realized, it might result in rupture of the uterus, or even in preterm delivery. Also, a specific congenital deformity – the Mobius sequence – has been identified in women who failed in their attempt at self-induced abortion with misoprostol and proceed to term delivery.41 First-trimester incomplete abortion. For women presenting with first-trimester incomplete abortions, the standard treatment for many years has been to evacuate the uterus. Vacuum aspiration using the manual vacuum aspiration (MVA) syringe is the method of choice recommended by WHO.37 The 2000 Cochrane review identified two eligible trials comparing vacuum aspiration with sharp curettage and showed that the former was associated with statistically less blood loss, less pain and shorter procedure time.42 One of the trials suggested that the risk of perforation was greater in the sharp curettage group but the numbers were too small to be reliable for this outcome. Early Pregnancy Assessment Units in many well-resourced countries now allow women a choice of immediate suction evacuation, medical management (use of misoprostol to complete uterine emptying) or expectant management (allowing the abortion to complete itself naturally), provided there is not excessive bleeding or evidence of infection.43 The last two options require good patient counseling and might also require ultrasound follow-up. Ten to twenty per cent of these patients will require uterine evacuation at a later stage. However, the immediate evacuation group has slightly more infection. There are no studies evaluating expectant or medical management in under-resourced countries, where the preferred treatment offered is still uterine

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evacuation. Given more difficulties in following up patients, lack of ultrasound at primary level, the possibility of untreated STIs, and high HIV prevalence, it could be argued that expectant or medical management might not be appropriate. Further research would be valuable in this context. Prophylactic antibiotics. The use of prophylactic antibiotics has been evaluated for firsttrimester abortion and miscarriage. There is evidence that it reduces subsequent infection for TOPs.44 There is insufficient evidence to indicate whether they should be used for incomplete miscarriages.45 In the UK, screening for Chlamydia trachomatis is suggested for all women with first-trimester TOPs and miscarriage.40 In underresourced countries, some incomplete miscarriages might have been induced and screening for sexually transmitted infections is rarely done, so there are more indications for prophylactic antibiotics. Analgesia/anesthesia. First-trimester suction evacuation of the uterus requires some form of analgesia and/or anesthesia. If the cervix is closed, a paracervical block provides effective analgesia for cervical dilatation. If the cervix is open, this might not be necessary and some form of conscious sedation is usually adequate for the suction evacuation. There are reports of uterine evacuation with no extra analgesia provided the cervix is open, and there is a support person for the women. The shift to conscious sedation with or without paracervical block allows these evacuation procedures to be done outside a formal operating theatre, which means they can be done with less delay. This reduces the risk of complications and allows a shorter hospital stay.37 There is a need for more research on women’s perception of pain and discomfort during these procedures to evaluate optimal analgesic requirements. General anesthesia is rarely required for such procedures, but might be considered in specific instances, such as a young rape survivor. Second-trimester procedures. Second-trimester procedures are associated with greater morbidity than those occurring in the first trimester. In well-resourced countries, medical termination involves mifepristone followed by prostaglandins, gemeprost or misoprostol, given vaginally.18 Suction evacuation might be required if the placenta appears incomplete. Dilatation and evacuation (D&E) is an alternative, which requires greater skill, ultrasound guidance and general anesthesia. Comparative trials have confirmed its safety in skilled hands. There is a need for randomized controlled trials comparing surgical and medical methods of second-trimester TOP.18 Extra-amniotic and intra-amniotic infusions of prostaglandin agents such as F2 alpha and E1 are now second-line procedures if the mifepristone/misoprostol regime fails. Mifepristone is not available in most under-resourced countries. Also, the skill of D&E, with the accompanying need for ultrasound and general anesthesia, means it is less frequently used as a method. In these situations, misoprostol can be used alone for second-trimester termination. The dose to delivery interval is longer than when given after mifepristone. Hysterotomy is occasionally required for failed procedures, and possibly in selected women with scarred uteri. In women admitted with an incomplete second-trimester abortion, misoprostol or intravenous oxytocin can be used to promote expulsion of the fetus, followed by uterine evacuation, if necessary. Prophylactic antibiotics are usually recommended for second-trimester procedures but this has not been subjected to trials.

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Tissue inspection. It is not necessary routinely to send aspirated products of conception for histological examination. However, visual inspection is recommended to confirm pregnancy products, exclude ectopic pregnancy and identify abnormal gestational trophoblastic tissue.18,37 Post-abortion care. Post-abortion care has been identified as a very important component of secondary prevention.28,29,46 It should involve provision of contraception, counseling about STI prevention and use of barrier methods, prophylactic antibiotics, and counseling about adverse complications from the procedure. The woman should be provided with information as to where she should go if she has any complications and requires emergency care. Clear referral routes for management of further complications after discharge are essential. Training health workers as providers of abortion care must include the above aspects of post-abortion care if it is to have an effective public health impact. Table 2 summarizes the essential components of comprehensive safe abortion care. Policies and guidelines for safe abortion care need to be accompanied by effective implementation. Healy et al describe a useful monitoring tool that can be used to perform a type of criterion-based audit to monitor countries, facilities or regions with respect to provision of safe abortion care.47 Tertiary prevention Correct and timely referral and management of women with unsafe abortion can reduce maternal deaths. The classification of unsafe abortion used in this section will be that described in the South African 1994 study.6 Table 2. Essential components of safe abortion care. Accessible services: services at level 1 (clinic and district hospital) with referral route to level 2 or 3 hospitals for complications Provider willingness Equipment, medications and skills available for: Safe TOP (law permitting) T1 TOP Mifepristone þ misoprostol Misoprostol þ MVA* T2 TOP Mifepristone þ misoprostol Misoprostol* D&E Equipment, medications and skills available for: Management of incomplete abortion T1 ICA Expectant Misoprostol MVA* T2 ICA Misoprostol* or oxytocin* Post-abortion care e counseling about sexually transmitted infections e provision of contraception e instructions about potential complications and where they can be managed D&E, dilatation and evacuation; ICA, incomplete abortion; MVA, manual vacuum aspiration; T1, first trimester; T2, second trimester; TOP, termination of pregnancy. * More appropriate in under-resourced settings.

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Haemorrhage An unsafe abortion in which there is severe haemorrhage requires resuscitation with crystalloids and blood, together with urgent uterine evacuation. Fresh frozen plasma may be necessary if coagulopathy develops. Moderate sepsis/morbidity An unsafe abortion with moderate morbidity from sepsis – pyrexia, tachycardia, uterine tenderness, and retained products of conception – requires further evaluation for evidence of organ failure: full blood count, blood culture and renal function tests. Treatment involves intravenous fluids, intravenous broad-spectrum antibiotics and evacuation of the uterus. This is best done using suction curettage under general anesthesia. Such patients need to be admitted as inpatients and observed for a minimum of 48 hours after the procedure or until the temperature and signs settle. This problem could be managed at a level one or district hospital.37,48 Severe sepsis/morbidity Women with severe morbidity, in addition to the above signs, might also have generalized peritonitis, organ failure and/or septic shock. Management involves assessment for organ failure: full blood count, blood culture, renal function tests, liver function tests, coagulopathy screen and chest X-ray. Treatment involves resuscitation with intravenous fluids, urinary catheterization and monitoring of urine output, consideration of central venous pressure monitoring, and monitoring in a high care or intensive care area. In severe cases, ventilation and ionotropic support might be necessary. Definitive treatment would include intravenous broad-spectrum antibiotics and evacuation of the uterus. Laparotomy with drainage of pus, or – more frequently – hysterectomy, is necessary if there is no response to the above treatment, there are signs of deteriorating organ failure or multiorgan failure, and/or septic shock requiring ionotropes. Coagulopathy would need to be corrected, with fresh frozen plasma or other blood products; a nasogastric tube might be necessary for paralytic ileus. Level one/district hospitals need to refer such patients urgently after initial resuscitation, uterine evacuation and commencement of intravenous antibiotics. Maternal deaths from severe abortal sepsis will occur if there are delays in performing necessary surgery and/or there is inadequate treatment of organ failure.48 Avoidable factors identified in a Zimbabwean study and in the South African Confidential Enquiry included: delay in referral from district or level one hospital to secondary or tertiary care, and prolonged attempts at antibiotic treatment in situations where surgery was indicated following poor response to 48 hours of antibiotics. There were also delays in performing life-saving hysterectomies.12,48 The algorithm in Figure 1 is derived from South African National Committee on Confidential Enquires into Maternal Deaths booklet on emergency management of common obstetric and neonatal emergencies. It summarizes the approach to management of women with severe morbidity from unsafe abortion.49 The antibiotic regimens marked with an asterisk (*) are those recommended in South Africa but can be modified according to local protocols and availability. The costs to the health sectors of treating women with severe morbidity would be easily outweighed by the costs of providing larger numbers of women with safe legal terminations of pregnancy. In addition, the emotional and physical cost of unsafe abortion to the women herself, and to her family, is entirely preventable by the provision of comprehensive safe abortion care.

Maternal mortality and unsafe abortion 545

SUMMARY Unsafe abortion remains an enormous preventable tragedy in many under-resourced countries, although there are indications that the incidence and associated mortality is decreasing in some countries. The WHO assembly in 1967, the program of action of the International Conference on Population and Development (1994) and the World conference on Women in Beijing in 1995, all reiterated the extent of the serious health Yes

Patient presenting with an abortion/miscarriage

Shocked?

Resuscitate the patient

No Assess the patient according to organ systems

Severe unsafe abortion

Safe abortion

Unsafe abortion

Manual vacuum aspiration Metronidazole* 2 g p.o. stat Doxycycline* 200 mg p.o. stat

Assess for organ system dysfunction with special investigations

Assess for organ system dysfunction with special investigations

If more than two systems affected: No organ systems affected Therapeutic antibiotics: Zinacef 750 mg t.d.s. ivi* Metronidazole 1 g b.d. pr* Gentamicin 240 mg imi* daily if no renal impairment Evacuation in theatre Monitor clinical response Repeat special investigation within 12 h of evacuations

If response discharge on oral antibiotics after 48 h

Therapeutic antibiotics: Zinacef 750 mg t.d.s. ivi* Metronidazole 1 g b.d. pr* Gentamicin 240 mg imi* daily if no renal impairment

If no response or if deterioration

Hysterectomy

Figure 1. Algorithm for management complicated abortion/miscarriage.

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consequences of unsafe abortion for women and the need for individual countries to take action.2 The reduction of maternal mortality and morbidity from unsafe abortion requires:  Effective accessible services for contraception, comprehensive abortion care and management of severe abortion complications.  Training of all levels of health worker in comprehensive abortion care.  Reform of abortion legislation in countries with restrictive laws.  Counselling and education around unsafe sex, unintended pregnancy and sexually transmitted infections, in particular HIV/AIDS.

Practice points  Irrespective of the status of laws governing TOP, health practitioners are ethically obliged to treat all women admitted with unsafe abortion in an effective, appropriate and non-judgmental manner.  Improving contraceptive coverage to teenagers, older women, post-abortal women, in addition to postpartum women, is essential to reduce the incidence of unintended pregnancies.  The manual vacuum aspiration syringe is an effective instrument for evacuating the uterus in incomplete abortion, and after cervical priming in first-trimester TOPs.  Misoprostol is an important medication for priming the cervix in first-trimester TOPs and for initiating/completing TOP/ICA in the second trimester.  Where available, mifepristone followed by misoprostol, can enable medical abortion alone.  The management of an abortion complicated by severe haemorrhage and/or sepsis constitutes a serious emergency, requiring aggressive treatment focusing on uterine evacuation, treating organ failure and hysterectomy if these measures fail.  Post-abortion care is an essential component of management of women with unsafe abortion.

Research agenda  Evaluation of interventions to reduce unintended teen pregnancy.  Evaluation of perceived contraceptive needs of women over 40 years.  Medical TOP and medical management of incomplete abortion in under resourced countries – feasibility and safety.  Value of prophylactic antibiotics in incomplete abortion.  Second trimester procedures; medical versus surgical in developing countries.  Near miss audits for unsafe abortion.

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