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Unsafe Abortion in the Third World by Oladipo A. Ladipo Professor in the Department of Obstretrics and Gynaecology, University College Hospital. Ibadan, Nigeria
bortion is one of the oldest methods of preventing unwanted births. Although universally practised, it is not universally accepted. It remains one of the most hazardous procedures when attempted by unqualified persons or by women themselves. As a result the rates of maternal injuries and deaths are inexcusably high. It is estimated that at least 200,000 women in the Third World die each year from botched abortions: According to a 1987 ·report, about 33 million legal abortions are performed in the world each year. If we add to this the estimated number of illegal abortions, it increases the . worldwide total to between 40 and 60 million abortions per year. Abortion is a global reproductive health problem which cannot be ignored. A variety of life-threatening complications can occur when induced abortion is badly performed. If health care services are immediately available, the woman may fully recover, but often there are lasting consequences including compromised reproductive function. Infection (sepsis) is the most common complication seen in developing country hospitals. Most cases of infection follow abortions induced by unskilled persons using non-sterile instruments and/or leaving products of conception in the uterus. The medical management of septic abortions include a number of expensive laboratory tests, surgery to "clean out" the infected contents of the uterus, high doses of antibiotics, and careful monitoring of the patient by medical personnel. Incomplete abortion (where some products of conception remain in the uterus) without infection may follow induced abortion (or spontaneous miscarriage). The woman suffers from 20
heavy or persistent bleeding and an enlarged uterus, and must be treated by surgery or vacuum aspiration. Damage to the cervix, vagina or uterus is usually caused by unqualified persons. When there is internal haemorrhage or intestinal injury, major surgery is required. Toxic reactions to drugs or chemicals can occur when patients use
native herbs or caustic chemicals to attempt abortion. Haemorrhage (bleeding) may be heavy or mild and protracted, and can be due to incomplete abortion, injury to the cervix, vagina or uterus, or to caustic chemicals which have been used to cause abortion. Medical management may involve surgery and often necessitates blood transfusion. Several hospital-based studies indicate that complications following abortions account for a majority of gynaecological emergency admissions to hospital in a large number of developing countries. The management of these complications puts a major strain on limited health resources.
Preventive measures Abortions are induced because pregnancy is unwanted, so it is rational to consider that sex education and widespread availability of safe and effective contraceptives would be highly effective preventive measures. Unfortunately, contraceptives are often not available to those who need them most. These include adolescents in all parts of the world (who are at the storm-centre of a transition in sexual behaviour) and many married women who live in depressed economic circumstances in developing countries. It ,is essential to provide accurate, understandable information about sexuality and contraception, using ct,llturally acceptable approaches, to enable sexually active women and men of whatever age to understand the various risks and responsibilities of sexuality and reproduction, and to enable them to avoid these risks, whether through abstinence or effective contraception. Such education could include a reproductive health curriculum in the schools; peer counseling enlisting the help of young men and women; brief, readable reproductive health education materials for public distribution; and educational programmes and materials for parents. Managing abortion complications presents a major health challenge in developing countries. However, the currently high levels of ' injuries and deaths can be reduced by improving access to qualified medical services and effective family planning. _
• This article was excerpted, with pennission, from a talk that Dr Ladipo presented at the Christopher TIetze Intemational Symposium on Women's Health in the Third World, Rio de Janeiro, October 1988. Proceedings of that symposium were published in December 1989 as a supplement to the International Journal of GynaecoJogy and Obstetrics. WORLD HEALTH,
A pril -M ay 1990