Survey of Unsafe Abortion in Selected Health Facilities in Ethiopia

Objective of the abortion survey    

Having recognized the seriousness of the unsafe abortion situation in the country and realizing the very high abortion related deaths, the 7th Annual Conference of the Ethiopian Society of Obstetricians and Gynecologists (ESOG), which took place in May 1999, passed a ten points resolution to improve the situation.  The Conference deliberations emphasized the importance of evidence-based data on abortion, and therefore   gave a high priority to research on abortion issues.  Therefore, this undertaking was in response to the recommendations of members of ESOG and the reproductive health community in the country that are partners in the national effort to reduce the high maternal death due to abortion.

Study Methodology

This survey is a cross sectional, descriptive study, conducted in nine of the eleven administrative regions of the country in order to generate information on the magnitude of unsafe abortion situation in Ethiopia.  The study was carried out from June 1, 2000 to Dec 31, 2000 in fifteen hospitals in nine of the eleven administrative regions of the country. A structured and pre-tested questionnaire was administered to cases of abortion that presented to the study sites. The interviewers were obstetricians and gynecologists, and in areas where there are none, general medical practitioners (GPs) were involved. A three-day orientation workshop was organized to both ob/gyn specialists and GPS in Addis Ababa before the launching of the study.

For cost analysis, the modified Delphi technique was adopted for this particular survey as there are no standard payments for services, and costs for medications/drugs vary from institution to institution in the public and private sectors. A panel of experts was established to develop models of resource use addressing three clinical conditions of unsafe abortion (mild, moderate and severe).  

Members of the panel comprised of Ob/Gyn specialists, general medical practitioners, midwives and nurse anesthetists at federal and regional levels. By applying this consensus building qualitative method, it was possible to estimate a reasonable cost that has been incurred by facilities surveyed. The application of the modified Delphi technique requires identified experts to be communicated more than once  (not more than three times) on this issue. Moderators will collect and compile information from the panel and communicate back results for consensus.

Communication was pursued through mail or hand delivery in order to maintain anonymity of members of the panel. In this exercise, maintaining anonymity will avoid peer pressure and senior member influence on the group.

Consent was obtained from all study participants after explaining the objectives and the procedures of the study. Ethical clearance was secured from the Ethiopian Science and Technology Commission.

Results

Socio-demographic:

A total of 1075 abortion cases were included in the study.  Among them, 58% of the cases were in the age range of 20-29 years. Women who presented with induced abortion were younger (mean 22+ 5) than women with spontaneous (mean age 26 + 6) abortion. Fifty three percent were housewives and two third of them were currently married. There were 26.5% women who were illiterate, and 27.5% of women with secondary education with abortion compared to other groups.

Types of abortions:

The leading four institutions that reported the highest number of abortions were Gondar 16.8%, Mekele (15.7%), Gandhi Memorial (12.8%) and Yekatit 12 (10.1%) Hospitals.

Three fourth of patients had spontaneous abortion and one fourth (25.6%)of them had induced abortion. This figure has to be cautiously interpreted, as women with this condition do not tell the truth because of fear and uncertainty. 

Awareness in family planning:

The majority (87 %) of women were aware of contraceptive methods, but only about half of them ever used a method. Of those pregnancies that ended in abortion 60%were unplanned and 50% were unwanted. Method non-use was responsible for 78% of pregnancies that occurred. Among women who induced abortion (25.6%) the most common reason for termination of pregnancy was contraceptive need. Whether this group of women decided to space or did not want a child at the time of abortion, it was not clear. However, according to the Ethiopia DHS 2000, the unmet need for family planning is 36%. Rape accounted only for 3% of all pregnancies that ended in abortion (i.e. 2.5% of all reasons for termination of pregnancies).

Methods of termination:

Fifty eight percent of women who induced abortion terminated the current pregnancy either by seeking the help of untrained personnel or by themselves with no assistance. The most frequent reason for hospital visit was vaginal bleeding and abdominal pain. Evacuation and curettage (E & C) was the commonest method (83.6 %) of evacuating the content of the uterus. Manual vacuum aspiration (MVA) was done in only 11% of cases.

Abortion Complications:

The major categories of complications identified were infection (28%,), genital tract injuries (12%,), foreign bodies in the genital tract (1.6%) and organ failure (13.1%). There were 13 deaths, which made the overall procedure related death 1,209/100,000 abortions.

Cost Analysis for abortion:

The panel of experts after considering the different clinical scenarios presented to it by the moderators, and taking into account the resources used to treat incomplete abortion by category of severity came up with reasonable and more accurate resource expenditure in the management of incomplete abortions.

Taking the six months period of the survey, and the constrained hospital budgets in the country, a lot of money has been spent to treat the 1075 cases of abortion in this study.

It was found out that for 450 mild cases of unsafe abortion, the cost of treatment was 55,813.5 Ethiopian Birr. The highest resource expenditure was for 610 moderate cases, which resulted in 261,332.85 Birr for treatment.  As the number of severe cases was few who underwent laparotomy (15 patients), the cost of treatment was only 15,113.55 Birr.  However, the total cost to treat incomplete abortion patients incurred by health facilities under this survey was Birr 332,259.90.  The average cost therefore, for incomplete abortion treatment per woman in Governmental health facilities was estimated at Birr 309.08.

Conclusions and recommendations

1.    The need for a strong National Family Planning Program (NFPP)

As shown in the Ethiopia DHS 2000, the unmet need for family planning is huge (36%).

It is apparent that the NFPP is not given high priority. However, Ethiopia is a signatory of the ICPD Program of Action, which says that it is the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, and therefore ensuring access to family planning information and services is an important activity in the reduction of deaths due to unsafe abortion. Most women in this study who resorted to unsafe abortion did  not use a method even when pregnancy was unwanted and unplanned. Although most respondents 86.6% were aware of family planning methods only 24% had used the services prior to the current abortion. The reasons for disparity between awareness and utilization of the services need to be explored further.

Recommendation:

There is a need to coordinate the efforts of all stakeholders to strengthen the national family planning program to enable women have access to quality information, counseling, and services in order to minimize unwanted and unplanned pregnancy and the resort to unsafe abortion.

2.    Introduction of Emergency Contraception

Abortion is a major reproductive health problem that affects all women of reproductive age groups, irrespective of age, societal and educational status, as well as place of residence, which has been confirmed in this study.

Over 45% of all abortions occurred in adolescents and the younger age group that are more likely to have irregular, unplanned, hurried and clandestine sexual behaviour.  Under such circumstances, use of emergency contraception can prevent a lot of unwanted pregnancies and hence reduce unsafe abortion.

Recommendation:

Introduction and promotion of emergency contraception in the country would greatly reduce the rate of unwanted pregnancy and thereby decrease the high rate of maternal deaths associated with unsafe abortion.

3.    Improve knowledge and skills of providers

Majority of the service providers (81%) resorted to sharp metallic curettage as opposed to MVA (11%), which is currently considered a safe method. Moreover, mid-level health workers initiated 27.8% of all abortions, which is an important role in abortion care provision. Although this activity is not formally recognized by the public sector, there is a urgent need to recognize this role, and organize trainings on post abortion care (PAC) at all levels.

Recommendation:

Initiate and strengthen a national training and services program on PAC.

4.    Provision of safe abortion services

Contraceptive method failure was responsible for 18% of all the pregnancies that resulted in unsafe abortion,  and was the second commonest reason for occurrence of unwanted and unplanned pregnancies. Rape also contributed 3% of the abortion cases.

Recommendation:

Until safe abortion services are available on demand, it is a high time that those women who become pregnant subsequent to method failure and rape be provided with safe abortion services.

5.    Liberalization of the abortion law

Unsafe abortion should get the necessary recognition as a major public health problem in the country. This recognition is expected to lead for the liberalization of the abortion law in the country.

Recommendation:

Conduct an advocacy work among policy makers by utilizing information generated from this study and from within the country  in order to bring about a change in the abortion law.

6.    National Task Force for Abortion

It is believed that the results of this study would be used to plan effective strategies, policies and programs to address the abortion problem in the country. Therefore, in order to give greater attention to the abortion problem in Ethiopia, and influence  policy makers to liberalize the abortion law as well as ensure quality PAC services, an organized  group of people working closely with the MOH and other interested  parties have to take the issue further.

Recommendation:

Take the lead in the establishment of a National Task Force for Abortion with the MOH and other agencies to address the serious abortion situation in Ethiopia.

7.    High cost of treatment for incomplete abortion

Using a combination of primary data generated from this study and secondary data from national figures it was found out there are an estimated 3 million births per annum in the country with estimated 212,000 abortion cases. The total medical cost incurred for the treatment of these cases will be close to Birr 65 million.  Taking the health service coverage into consideration, and the availability of existing services, at least 50% of the estimated cost, which is over Birr 32 million could be incurred by patients or the health service or both.    The above projections clearly demonstrate the fact that abortion is not only a public health problem of national significance in terms of morbidity and mortality, but it has also got an economical dimension, which should not be underestimated.

Recommendation:

Conduct dissemination activities on the results of this survey at federal and regional levels particularly on the cost issue. The available meager resources of the country should not be consumed for the treatment of abortion.

Full document available at the  secretariat