Abortion: women more at risk of death in fragile and conflict-affected settings

Header: © Illustration by Alice Wietzel

Severe complications following unsafe abortions 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.

• AMoCo - qualitative research (in English)

• AMoCo - quantitative research (in English)

Around 70% of maternal deaths occur in sub-Saharan Africa (1). Among the five main causes are abortion-related complications - an area in which little progress has been made in recent decades. Yet most abortion-related deaths are the result of unsafe induced abortions (2), which could be largely avoided by providing comprehensive abortion care, including post-abortion care, contraception and safe abortion services.

“This study clearly shows that if we want to dramatically reduce maternal mortality to meet the 2023 Sustainable Development Goals, safe abortion care and post-abortion care must be accessible to all women. It must be a core component of health services alongside other sexual, reproductive, and maternal care,” says Lenka Beňová, head of ITM's reproductive and Maternal Health Unit.

“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 primary health centres and in hospitals," explains Dr Estelle Pasquier, PhD researcher at the Institute of Tropical Medicine (ITM) 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 primary healthcare level.”

The AMoCo* study, conducted by Médecins Sans Frontières, Épicentre, The Institute of Tropical Medicine in Antwerp, Ghent University, Guttmacher Institute and Ipas, in partnership with the Nigerian and Central African Ministries of Health, - and co-funded by MSF and ELRHA/R2HC - 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 (3).

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 medical standards. In these two hospitals, more than 50% of women admitted for an abortion-related complication presented with a severe form, mainly haemorrhage (72% in the Nigerian hospital and 58% 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 ratio in the world (4). A study conducted by the Central African Ministry of Health and the United Nations Population Fund (UNFPA) estimated that abortion-related complications accounted for almost one in four maternal deaths (5). In the Bangui hospital in which the AMoCo study was conducted, admissions for abortion-related complications accounted for 20% 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 patients were adolescents aged 18 and under.

While admissions for abortion-related complications are rarer in the Nigerian hospital than in the Central African hospital (4% of admissions against 20%), more than two-thirds of the women surveyed in Jigawa State presented with a severe complication.

Poor knowledge of safe abortion care options

Around a quarter of the women interviewed in the hospital in Jigawa and 45% of those in Bangui said that they had induced their abortion. More than two-thirds of those surveyed in Bangui and almost all (95%) 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.

Difficulties accessing methods of contraception

Difficulties in accessing methods of contraception are also one of the root causes of unwanted pregnancies. Respectively, only 3% of the women surveyed in Jigawa State and 37% 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.

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. 27% of the women surveyed in Nigeria and 16% 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.

In other cases, women simply want to keep their abortion secret.

When the symptoms get worse, they 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 (4% of admissions against 20%), 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. 67% of women with no significant bleeding had anaemia (compared with 38% 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 (5).

In addition, 61% 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.