Severe complications following unsafe abortions are up to seven times more likely in two hospitals in fragile and conflict-affected settings. These are the findings of one of the very first studies on the subject, carried out in two referral hospitals in Bangui in the Central African Republic and Jigawa State in northern Nigeria. Behind the statistics, real stories of real women – and a universal vulnerability.
“I was distraught. I had drunk the traditional medicine. Before that, someone had shown me how to insert a piece of iron into my vagina... It was a piece of iron like this [she shows the interviewer the size],” says Rasha*, a 32-year-old woman admitted to Bangui referral hospital with potentially life-threatening abortion-related complications.
“This person told me it would dilate the cervix, but it didn't work ... She also told me to boil the roots of a plant called Kava with natron [sodium carbonate] and then drink the mixture. After drinking it, I didn't feel well. I felt sick to my stomach and dizzy. My stomach was churning. I couldn't get out of bed. The pains were intense,” she says.
Around 70 per cent of maternal deaths occur in sub-Saharan Africa.
The AMoCo** study, conducted by Médecins Sans Frontières (MSF), Épicentre, Institut Guttmacher and Ipas, in partnership with the Nigerian and Central African Ministries of Health, shows that severe complications were five to seven times more frequent in the two referral hospitals studied than in African hospitals in the more stable settings studied by the World Health Organisation (WHO) using a similar methodology.
- Severe abortion-related complications include potentially life-threatening complications, near-miss cases and deaths, as defined in the WHO Multi-country Study on Abortion (WHO-MCS-A) using a set of standardised clinical, biological and treatment criteria.
- An unsafe induced abortion is carried out by people who do not have the necessary skills to perform it and/or who do not comply with the medical standards in force.
In these two hospitals, more than 50 per cent of women admitted for an abortion-related complication presented with a severe form, mainly haemorrhage (72 per cent in the Nigerian hospital and 58 per cent in the Central African hospital).
The severity of the complications observed can be explained by the inadequacy of post-abortion care services and the many barriers to accessing these services. This is compounded by an increased risk of exposure to sexual violence in these settings, as well as difficulties in accessing contraception. These factors in turn increase the risk of unwanted pregnancy and recourse to unsafe abortion, particularly in places where abortion laws are restrictive.
The leading cause of maternal mortality in the Central African Republic
With 829 deaths per 100,000 live births, the Central African Republic has one of the highest maternal mortality rates in the world.
In the Bangui hospital in which the AMoCo study was conducted, admissions for abortion-related complications accounted for 20 per cent of all pregnancy-related admissions during the period studied, which corroborates these results. More than two-thirds occurred during the first trimester of pregnancy. More than a quarter of the women were adolescents aged 18 and under.
A woman explained... that if I waited any longer, I might die because I was bleeding out. The motorbike driver also said that he had taken a woman in the same condition to hospital, and that it had saved her life. He told us to hurry and that's how they got me here.Testimony of a 35-year-old woman admitted to Bangui referral hospital with near-miss abortion-related complications.
Poor knowledge of safe abortion care options
Around a quarter of the women interviewed in the hospital in Jigawa and 45 per cent of those in Bangui said that they had induced their abortion. More than two-thirds of those surveyed in Bangui and almost all (95 per cent) of those surveyed in Jigawa State had used dangerous methods to induce an abortion, including blunt metal objects or manioc sticks used in septic conditions, injections, traditional herbs and remedies, or medicines.
The risk of very severe complications, including death, was more than three times higher among women who reported an unsafe induced abortion than among other women in the Bangui hospital.
Sources of information about induced abortion were most often informal, usually family members, friends or colleagues. The choice of abortion method seemed to be based more on perceived effectiveness and ease of access than on safety.
When the partner is informed of the pregnancy, he or she is often involved in the decision-making process and choice of abortion method. Spouses who abandon their partners often leave them with no choice but to have an abortion.
Celine* is a 27-year-old woman who was admitted to Bangui referral hospital with near-miss abortion-related complications...
“It's was just a boyfriend thing [but] I got pregnant... I tried to abort myself but it didn't work, so I had to go and see a mother in one of the neighbourhoods,” says Celine*.
“She asked me for 15,000 CFA francs for the abortion, but I only had 13,000 CFA francs, so I gave them to her. She injected me with medicine and she dilated my cervix with a cassava stem and the foetus fell out. Afterwards, I started having abdominal pains,” she says.
Tracy* is a 19-year-old woman who was admitted to Bangui referral hospital with potentially life-threatening abortion-related complications.
“He's preparing his application for military training... It's better to abort this pregnancy if he's not going to be here, he [won't be] comfortable until we've done away with it. At the moment, he has no money to help me with my small business so that I can take care of this pregnancy. How are we going to manage?” says Tracy.
“[He] was the one who went to see [the hospital health worker]. He said he wanted to have an abortion with me because he's not ready at the moment, so he wants us to do the curettage. [The health worker] agreed,” she says.
Magda* is a 15 year-old girl who was admitted to Bangui referral hospital with near-miss abortion-related complications...
“When I spoke to him about the pregnancy, he didn’t reply. One day, I told him that I wasn't feeling well, and he started shouting at me, saying that he wasn't responsible for the pregnancy,” says Magda.
“When my partner said this to me, I was confused and wondered what would happen to me if I carried on with the pregnancy. Would I be able to take care of the baby? I couldn't do it on my own, so I bought some medication... [Since then], my partner has run away,” she says.
*Names changed to protect identity.
Difficulties accessing methods of contraception
Difficulties in accessing methods of contraception are also one of the root causes of unwanted pregnancies. Only nine per cent of the women surveyed in Jigawa State and 37 per cent of those in Bangui said that they were using some form of contraception at the start of their pregnancy.
In Nigeria, the main barriers to the use of modern contraceptives were refusal on the part of the husband and family, the fact that they did not know they could become pregnant and their religious beliefs.
In Bangui, fear of the side effects of contraception was the main reason reported. The women also explained that they faced difficulties ensuring the continuity of their contraception, with a lack of available alternative methods, high transport costs and opening hours that made it impossible to buy them.
“I didn't have anyone to go with me, and what's more I didn't have the time. I leave for work at seven in the morning and I get home at 11 o'clock at night. I don't have time to pick up the pill ... I [simply] don't have the time,” says a 32-year-old woman admitted to Bangui referral hospital with potentially life-threatening abortion-related complications.
Extremely long delays in accessing care
The AMoCo study also describes women’s long and difficult post-abortion care pathway, exacerbating the complications and the risks they face. Half of them took two days or more after the first symptoms appeared to get to a suitable health facility. Twenty-seven per cent of the women surveyed in Nigeria and 16 per cent in the Central African Republic took six days or more. Symptoms are often not perceived as serious at first, let alone as a priority. Some women don't realise that they are pregnant.
“I had pain in my lower abdomen and here [she touches her back and hips with her hands], it hurt a lot... At one point, I wondered if it wasn't because of how far I have to walk every day,” says Martha*, a 27-year-old woman admitted to Jigawa State referral hospital with near-miss abortion-related complications.
Alisha*, a 30-year-old woman admitted to Jigawa State referral hospital with near-miss abortion-related complications...
“I was sitting down when all of a sudden the bleeding started. I didn't worry about it. It was after two days that things got serious; that's when the bleeding became heavy and persistent,” says Alisha.
In other cases, women simply want to keep their abortion secret, such as Dominique*, a 21-year-old woman admitted to Bangui referral hospital with near-miss abortion-related complications...
“I had often heard that after the curettage, you felt better... I thought that one day or other the foetus would come out and I'd feel better... I couldn't swallow anything. I couldn't get out of bed... I was in pain day and night,” says Dominique.
“I took the medication that [the abortionist] gave me, but it wasn't any good... As things got more complicated, I got scared, because my family wouldn't have agreed to me having an abortion. I didn't tell anyone about my situation, I became very withdrawn and shut myself away at home,” she says.
Patricia*, a 35-year-old woman who was admitted to Bangui referral hospital with near-miss abortion-related complications...
“If there had been a means of transport, a safe way of getting patients to hospital, it would [have] helped me... There should be ambulances for health facilities like the maternity hospital... To take me to the maternity, there was no ambulance, so the person accompanying me had to go to the main road to look for a motorbike,” says Patricia.
“With no transport and insecurity in the area, I had to wait until daylight to leave my house... The worst thing was that it was the weekend, a Sunday, and on that day it's hard to find any transport; the taxis don't really work on Sundays. I lost a lot of blood that day and nearly died,” she says
Winnie*, a 32-year-old woman admitted to Jigawa State referral hospital with potentially life-threatening abortion-related complications...
“You see, it's not like our house is by the side of the road. And there was no way I could sit on a motorbike. So, they had to use a cart to carry me to a car,” says Winnie.
*Names changes to protect identity.
When the symptoms get worse, women often decide to return to the person who performed the abortion or to untrained care providers, which further increases delays in seeking care and accessing adequate treatment. Women initially try to manage the symptoms at home with medicines they have bought themselves (including pharmaceuticals and traditional treatments).
Delays in accessing care are compounded by a lack of information about appropriate health facilities to care for the women. They must also find the money to pay for transport and cover the costs of treatment, as well as someone to accompany them. For example, most of the women who took part in the study didn’t know that services at Bangui hospital were provided free of charge.
Aggravating factors in Nigeria
While admissions for abortion-related complications are rarer in the Nigerian hospital than in the Central African hospital (four per cent of admissions against 20 per cent, respectively), more than two-thirds of the women surveyed in Jigawa State presented with a severe complication.
Chronic anaemia among women in this very poor rural region probably worsens the complication. This could go some way towards explaining the higher proportion of women with severe complications. Sixty-seven per cent of women with no significant bleeding had anaemia (compared with 38 per cent in the Central African Republic), suggesting that they probably had underlying chronic anaemia.
National surveys have confirmed this data, showing that the proportion of women of childbearing age with anaemia in Jigawa State is one of the highest in the country.
In addition, 61 per cent of abortion-related complications occurred during the second trimester, i.e. later than in the Bangui hospital, which may also explain why they were more severe.
Unsafe abortion remains one of the leading causes of maternal mortality in the world, and the only one that is almost entirely preventable.
“In fragile or conflict-affected settings, as elsewhere, in order to save the lives of many women and reduce their suffering, we need to provide access to free contraceptive services offering a wide range of methods, both in general healthcare centres and in hospitals,” says Dr Estelle Pasquier, a medical researcher at Epicentre and co-leader of the AMoCo study.
“We need to invest in improving communities’ knowledge of safe contraceptive and abortion methods, and make post-abortion care and safe abortion care easily accessible, including at basic healthcare level.”
*Names changed to protect identity.
**AMoCo : Abortion-related Morbidity and mortality in fragile and Conflict-affected settings. Conducted in collaboration with the Central African Republic and Nigerian Ministries of Health, co-funded by MSF and ELRHA/R2HC, the AMoCo study gathers data from 1,068 women presenting with abortion-related complications.