May 30, 2011 - terminated by induced abortion in Africa is only 15%, the lowest for any ..... by the health assistant, 366(28.3%) self induced and 306(23.7%) by.
The Burden of unsafe Abortion In Sub Saharan Africa In Particular Ethiopia
May 30, 2011
A Review By Yilak Getnet ACIPH-Hawassa University Joint MPH Program
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Introduction (summary) It was estimated that in 2003 approximately 42 million10 pregnancies were voluntarily terminated: 22 million safely and 20 million unsafely. (11)WHO defines unsafe abortion as a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards or both.(1) An estimated 21.6 million unsafe abortions took place worldwide in 2008, almost all in developing countries. Numbers of unsafe abortions have increased from 19.7 million in 2003 although the overall unsafe abortion rate remains unchanged. Deaths due to unsafe abortion remain close to 13% of all maternal deaths. Although unsafe abortions are preventable, they continue to pose undue risks to women’s health and lives.(1) Sub-Saharan Africa has the world’s highest maternal mortality ratios. In this region, 3.9% of maternal deaths are due to induced abortion. arising from an estimated 19 million unsafe abortions performed annually . Africa accounts for 25% of all illegal abortions performed worldwide and less than 1% of all legal abortions The estimated proportion of all pregnancies terminated by induced abortion in Africa is only 15%, the lowest for any continent. This is partly due to strict sanctions against abortion in most African countries, but also from a desire for larger families than the rest of the world. Africa is also one of the most dangerous regions to have an abortion: the ratio of abortion deaths per100, 000 procedures is less than 1/100,000 in developed countries, for developing countries is 330/100,000 and for Africa alone averages 680/100,000. (2) In almost all countries (98%) around the world, abortion is legally permitted to save a woman's life, while close to two-thirds of countries allow abortion to preserve a woman's physical health (63 percent) or mental health (62 percent). However, safe abortion services are often not available to the full extent permitted by law, in part due to lack of awareness of the legal status in communities and indifference among health providers.(3) Countries such as Cambodia, Guyana, Nepal, South Africa and, most recently, Ethiopia are in the process of implementing less-restrictive abortion laws with varying success and therefore show unsafe abortions in parallel with safe and legal services.(1) Unsafe abortion also places a huge burden on health care systems, especially in Sub-Saharan Africa, women with incomplete abortion account for half of gynecological admissions at hospitals. Their treatment has traditionally required several days of hospital stay, occupying significant staff time, antibiotics, anaesthesia, intravenous fluids and blood transfusion. Some patients with severe complications end up in intensive care units or may require renal dialysis. (3) Ethiopia has the fifth highest number of maternal deaths in the world: One in 27 women die from complications of pregnancy or childbirth annually.2.In 2005, Ethiopia expanded its abortion law, which had previously allowed the procedure only to save the life of a woman or protect her physical health. Abortion is now legal in Ethiopia in cases of rape, incest or fetal impairment. In addition, a woman can legally terminate a pregnancy if her life or her child’s life is in danger, or if continuing the pregnancy or giving birth endangers her life. A woman may also terminate a pregnancy if she is unable to bring up the child, owing to her status as a minor or to a physical
3 or mental infirmity. Notwithstanding the new law, almost six in 10 abortions in Ethiopia are unsafe.(4) Unsafe abortion endangers health in the developing world, and merits the same dispassionate, scientific approach to solutions as do other threats to public health. Although the remedies are available and inexpensive, governments in developing nations often do not have the political will to do what is right and necessary. The beneficiaries of access to safe, legal abortion on request include not only women but also their children, families, and society—for present and future generations.(5) Women have always had abortions and will always continue to do so, irrespective of prevailing laws, religious proscriptions, or social norms. Although the ethical debate over abortion will continue, the public-health record is clear and incontrovertible: access to safe, legal abortion on request improves health. As noted by Mahmoud Fathalla, “Pregnancy-related deaths … are often the ultimate tragic outcome of the cumulative denial of women’s human rights. Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving. Simply put, they die because they do not count.(5) When carried out according to appropriate clinical guidelines and with trained personnel, abortion has the lowest physical risks for women of any significant medical intervention.(6) However, for most women in the developing world, abortions are often conducted in unsanitary conditions by untrained personnel. It is estimated that between 10 and 50% of women who undergo unsafe abortions need medical care for complications. These complications include infection, hemorrhage and injury to internal organs, and can lead to long-term health problems such as chronic pain, pelvic inflammatory disease, and infertility. (3) Today, African governments are faced with the challenges of the Millennium Development Goal of reducing maternal mortality by 75% by 2015, there needs to be a clear recognition that this will not be possible without addressing unsafe abortion which results in half of maternal deaths. And unsafe abortion cannot be reduced unless an enabling legal and clinical environment is created that puts the woman's interest first and empowers skilled providers to save lives of all women (not just the rich), is created.(3) In June 2009, the UN Human Rights Council passed a landmark resolution recognizing preventable maternal mortality and morbidity as a pressing human-rights issue that violates a woman’s rights to health, life, education, dignity, and information.(2) Abortion services need to be expanded to the full extent of the law, and appropriate measures and changes to health systems implemented. Governments and intergovernmental and nongovernmental organizations will need to deal with unsafe abortion as a major public health concern, a call which was made by the World Health Assembly in 1967 that has grown in urgency and significance.(1)
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Relevance of the issue for public health policy and manage program in Ethiopia A cross-country comparative study undertaken in 1993/1994 was conducted in three countries (Zambia, Uganda and Malawi) at selected districts and tertiary care hospitals to provide a basis for continued policy dialogue and reform to address the problem of death due to abortion complications among the ECSA(East, Central and Southern Africa) Health Community countries. These data represent the situation as it was in the region some years ago and the paper describes important implications of the findings for policy and program development. This research provided some impetus for stakeholders in these countries to put safe abortion and management of abortion complications on their health agenda. Ensuring that research results will be shared with appropriate decision-makers is a key to maximizing the extent to which research findings may affect policy and program advocacy. At a 1994 CHRCS conference, Health Ministers from 12 Commonwealth countries reviewed and endorsed the results of this study. In a 1995 ECSA Director Joint Consultative Committee meeting, participants discussed the study findings and developed regional action plans which were subsequently endorsed by the Health Ministers' at their 1995 annual conference. The anticipated short-term outcome of this study was increased awareness among African health officials about the problem of incomplete abortion in Sub Saharan Africa, especially CRHCS/ECSA countries(7) (Botswana, Kenya, Lesotho, Malawi, Mauritius, Namibia, Seychelles, South Africa (added November 1994), Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. In May 1995, the CRHCS changed its name to the East, Central and Southern Africa Health Community (ECSAHC).)
This cross country comparative study provides evidence that research can affect policy and program advocacy in a country. As a public health professional I believe that this review on the condition of unsafe abortion in Sub Saharan Africa can used as input for improvement of policy and programs in Ethiopia.
Objectives of the review General objective To assess the burden of unsafe abortion in Sub Saharan Africa in Particular to Ethiopia and identify the major consequences of unsafe abortion
Specific objectives
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To examine the levels and pattern of, as well as the factors associated with pregnancy termination To measure the incidence of legal and illegal induced abortion in this region. To examine patterns of abortion-related morbidity and treatment To determine the current and future potential capacity and quality of PAC (post abortion care) service delivery in public hospitals, health centers and private health facilities. To assess the potential impact of private facilities in expanding access to post abortion care (PAC) To assess factors which influence decisions for utilization of abortion related services at community level
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To determine the primary abortionist while the patient is in hospital, the type of material used to terminate the pregnancy. To assess changes in maternal mortality that are achievable if unsafe abortion were replaced by medical abortion
Literature review methodology The literature review involved a computerized search for published literature using numerous bibliographic databases available in Sub Saharan Africa countries on abortion. Ultimately 94 published articles were identified. The published literature consisted primarily of articles presented in peer review journals and catalogued by the Library of HINARI/PubMed Advanced Searching. The search for literature included articles from other journals those not peerreviewed, such as International guidelines, reports, official country papers, The main criteria for selecting documents were that they be published between 1990 and current time 2011 and that they reflect research conducted in, or information gathered on, one or more SSA countries. Under these criteria, the following documents were deemed most relevant: hospital- and community-based epidemiological studies; studies focusing on provider attitudes toward and experiences with abortion and/or post-abortion patients; studies focusing on women's perspectives on the quality of and access to emergency abortion treatment services; studies documenting the social and financial costs of abortion; studies demonstrating program linkages between treatment of abortion complication services and other reproductive health services; clinical studies documenting the safety and effectiveness of different abortion treatment modalities; and articles covering the general legal situation. Computerized searches were carried out using select key words (Unsafe abortion and Sub Saharan Africa) on the following databases: HINARI/PubMed Advanced Searching a cataloguing software provided by the WHO, MEDLINE, a clinical and medical database maintained by the United States (US) National Library of Medicine and accessed through the MEDLARS system POPLINE, which features population and family planning articles and is maintained by the Johns Hopkins University/CCP/ PCS/PIP. African journal of RH, WHO web site ,Alan Guttmacher Institute (AGI) International Family Planning Perspectives, The Lancet, International Journal of Health Research, East African Medical Journal,© Oxford University Press , BMJ. International Perspectives on Sexual and Reproductive Health, Web site of I pas Ethiopia. P LoS ONE and JOURNAL OF ERITREAN MEDICAL ASSOCIATION JEMA were my major source of the published literature.
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Findings of the Review The Commonwealth Regional Health Community Secretariat undertook a study in 1994 to document the magnitude of abortion complications in Commonwealth member countries. The study involved two components: 1) a literature review on abortion in SSA covering the years 1980-1994 (99 published and 169 gray literature articles) and 2) primary data collection in three Commonwealth countries (Malawi, Uganda, Zambia) to yield more recent findings The results of the literature review component of that study, and research gaps identified as a result of the review, are presented in this article. This review was published on HEALTH POLICY AND PLANNING, © Oxford University Press in 1996 The literature review findings of this review indicate a significant public health problem in the region, as measured by a high proportion of incomplete abortion patients among all hospital gynecology admissions. The most common complications of unsafe abortion seen at health facilities were hemorrhage and sepsis. Studies on the use of manual vacuum aspiration for treating abortion complications found shorter lengths of hospital stay (and thus, lower resource costs) and a reduced need for a repeat evacuation. Very few articles focused exclusively on the cost of treating abortion complications, but authors agreed that it consumes a disproportionate amount of hospital resources. Studies on the role of men in supporting a woman's decision to abort or use contraception were similarly lacking. Articles on contraceptive behavior and abortion reported that almost all patients suffering from abortion complications had not used an effective, or any, method of contraception prior to becoming pregnant, especially among the adolescent population; studies on post-abortion contraception are virtually nonexistent.(8) Almost all articles on the legal aspect of abortion recommended law reform to reflect a public health, rather than a criminal, orientation. Research needs that were identified include: community-based epidemiological studies; operations research on decentralization of postabortion care and integration of treatment with post-abortion family planning services; studies on system-wide resource use for treatment of incomplete abortion; qualitative research on the role of males in the decision to terminate pregnancy and use contraception; clinical studies on pain control medications and procedures; and case studies on the provision of safe abortion services where legally allowed.(8) Another study that examines the levels and pattern of, as well as the factors associated with, pregnancy termination in seventeen Sub-Sahara African countries. The study Used the 2000 round of demographic and health survey (DHS) data sets for the countries, interview during the surveys, univariate and bivariate method of analysis. According to the study, in all the 17 countries examined, age and marital status are critical predictors of having ever had a terminated pregnancy. The odds of having ever had a terminated pregnancy are higher (and as age increases) among the older age groups compared to respondents in age group 15-19, which is the reference category. The odds of having ever had a terminated pregnancy is also higher for ever (currently and formerly) married women compared to the never married. This is particularly marked in Rwanda where the odds of having ever had a terminated pregnancy is about 54 and 32 times (for currently and formerly married women, respectively) that of those that have never married.(9) A study was conducted In 2008 to measure the incidence of legal and illegal induced abortion after the change in the law in Ethiopia It was published on the journal of International Perspectives on Sexual and Reproductive Health, in 2010.
7 According to this study a nationally representative survey of a sample of 347 health facilities that provide post abortion or safe abortion services estimated 382,000 induced abortions were performed in Ethiopia, and 52,600 women were treated for complications of such abortions. According to their estimate approximately 103,000 legal abortions provided by surveyed health facilities in 2008 accounted for 27% of all induced abortions that year. Nationally, the incidence of facility-based legal abortion was six per 1,000 women aged 15–44,Nationally, the annual abortion rate was 23 per 1,000women aged 15–44,and the abortion Ratio was 13 per 100 live births. (3) This rate is much lower than WHO’s estimated rate for 2003 for Eastern Africa (39 per 1,000), the sub region within which Ethiopia falls, and somewhat lower than the rate for the whole of Africa (29 per 1,000). (10) This study also showed that the majority of abortions among non poor women were likely performed by trained health professionals, such as physicians, clinical officers, nurses or midwives (an estimated 88%of urban women and 65%of rural women). Among poor women, about 57%of urban women and 36% of rural women are considered likely to obtain their abortions from trained professionals—which is understandable given that they may be less likely than more affluent women to know about safe providers and to be able to afford a safe procedure, and because the availability of trained providers in rural areas is much lower than in urban areas. However, complications may result from procedures carried out by trained providers who have little experience or who work in unhygienic settings.(10) Another important point in this study was that the national annual rate of women treated in health facilities for complications from induced abortion was 3.2. The rates in Addis Ababa (6.7) and in the combined two urban regions (25.4) were higher than the national average, likely because of better access to health facilities; urban facilities serving women who reside in their cities’ environs, spuriously inflating the rates; In addition, a substantial proportion of abortions (especially among rural and urban poor women) entail a high risk of complications because they are carried out by informal and untrained providers (traditional healers, lay practitioners, pharmacists or the women themselves).(10) A facility based cross sectional study was conducted in 2007–2008 to examine patterns of abortion-related morbidity and treatment and to generate national estimates It was published on the journal of International Perspectives on Sexual and Reproductive Health in 2010.Data were collected on 1,932 women seeking post abortion care at a nationally representative sample of 344 public and private health facilities. In addition, staff respondents at 337 facilities provided information on their facility’s services and caseload. Accordingly almost 58,000 women sought care for complications of induced or spontaneous abortion in 2008.Three quarters of the women received care in government facilities. In this sample, 14% of women told their provider that they had done something to try to cause an abortion (either by themselves or with the assistance of another person) prior to seeking post abortion care. 7% of all women presented with signs of mechanical injury to or foreign bodies in the intrauterine area, an indication of the invasiveness of unsafe abortion procedures. Two percent of all women were found to have a foreign body inserted in their vagina or uterus. Almost six in 10 women presenting for post abortion care had symptoms of low severity, as they showed no unusual morbidity other than pain and bleeding.(11) However, 41% of women had either moderate or severe morbidity, indicating that their condition was more serious or deteriorating. Fourteen percent of women were classified as moderately ill,
8 as they had “offensive” products of conception (infected retained products), a slightly elevated temperature (37.3–37.9°C) or localized peritonitis. The remaining 27% had severe morbidity— signs of infection, evidence of shock, mechanical or foreign body injury, elevated pulse, organ failure or generalized peritonitis—or died. Seriously ill women (those with moderate or severe morbidity) more often sought care in public facilities than in private ones and were as likely to go to a health center as to a hospital for care. More than 13,000women seeking post abortion care required a hospital stay of at least 24 hours. The case fatality rate among women seeking post abortion care in public hospitals, where the most serious complications were seen, was 628 per 100,000. (11) I pas Ethiopia collaborated with the Regional Health Bureaus from July to September 2000, to conduct a cross-sectional post abortion care (PAC) assessment in three regions: Oromia, Amhara and Addis Ababa. The main objective of the assessment was to determine the current and future potential capacity and quality of PAC service delivery in public hospitals and health centers. A total of 120 health facilities were included in the study. In the three regions, a total of 120 health facilities, 27 hospitals and 93 health centers were assessed to determine their capacity to respond to post abortion clients. 54% of all facilities surveyed were able to respond to patients suffering from abortion-related complications by performing a uterine evacuation with either sharp curettage or manual vacuum aspiration (MVA).The capacity was much higher in the Amhara and the Oromia regions, where all of the hospitals and 61% of the health centers sampled were able to perform uterine evacuations. Only three (13%) of all of the public sector health facilities in Addis Ababa were able to do so. (12) This study found that only half of the facilities sampled are able to clinically manage an incomplete abortion; most of these facilities are hospitals. The majority of health centers (57%) in these areas could not manage simple abortion complications in their facilities. The women living in those catchment areas may be several hours from the nearest PAC services and may further delay management of their complications by seeking help nearby in a facility that is not prepared to respond. (12) Another cross-sectional study of health practice also in Addis Ababa, Amhara and Oromia in 2001-2002 assessed the potential impact of private facilities in expanding access to post abortion care (PAC) eligible facilities. The paper was published on Ethiopian journal of Health Development in 2003 It found MVA used in 61% in Addis Ababa where as 80% of Amhara and Oromia used sharp curettage. Majority of the facilities have at least one GP, nurses and mid wives .High level of disinfection of non autoclave instruments needs improvement .The study concluded that private health facilities can contribute substantially if given necessary guidance and support with proper monitoring and evaluation. (13) One of the Key messages WHO on Unsafe abortion: the preventable pandemic, indicate that Manual vacuum aspiration (a handheld syringe as a suction source) and medical methods of inducing abortion have reduced complications.(14) (5) Since this message is evidence based a lot has to be done to increase the accessibility of MVA in Ethiopia.
9 A cross-sectional study to assess the status of quality of PAC in health facilities of Amhara and Oromia regional states was conducted from November 2002 to March 2003.Eleven health facilities (five in Oromia and six in Amhara Regions), 103 post-abortion patients and 87 health service providers were included in the study. The paper was published on Ethiopian journal of Health Development in 2008 This study showed that although facilities were found to be prepared to manage abortion complications, some patients were delayed from receiving services because of requirement to pay before getting services, and to buy drugs and supplies from other sources. Patient-provider interaction was generally satisfactory as viewed by the respondents. Majority (88.3%) of patients felt that PAC services maintained confidentiality. Patients were not informed about the steps of each procedure. Nearly two-third of service providers informed the patients about the cause of their problem, but only 50.5% of them told the outcome of treatment. Information provision regarding important precautions and warning signs was uniformly very low in all study facilities. Only 53.4% of patients left the facilities counseled about family planning and 44.7% with contraceptives. But, 84.5% of women do not plan pregnancy within three months following the abortion. According to this study great majority of the patients responded that they were satisfied with services they have obtained. Dissatisfaction included maltreatment by service providers, and inconvenient setup of service delivery. Patient assessment was principally based on last menstrual period and bimanual pelvic examination in most of the facilities. Service providers do not usually stick to infection prevention and universal precautions.(14) A descriptive cross-sectional study that used both quantitative and qualitative study techniques was carried out to assess factors which influence decisions for utilization of abortion related services at community level .The study was conducted in six selected districts (woredas) within the three big regions of the country, namely Amhara, Oromia and SNNPR. The study was conducted in September 2006 and published on Ethiopia Journal of Health Development on 2010.The study population comprised randomly selected 1,492 women of reproductive age, service providers. According to the study majority of respondents said that they prefer public health facilities. According to their respondents, the reason why women do not visit health facility for PAC services include lack of community support, unavailability of services, services are expensive, facilities are distantly located and lack of means of transportation. From the multivariate analysis it appears that public health facilities are preferred by younger respondents, those with no education, those with no history of unwanted pregnancy and those with better income. The qualitative study indicated that women do not go to health facilities for PAC mainly because of inappropriate treatment by providers at the health facilities.(6) This study concluded that public health facilities especially health centers are the most preferred but there are barriers that should be improved. Introduction of supportive supervision should be considered as a tool for improving quality of care. A mechanism should be in place to obtain community opinion regularly and use it to continuously improve services. To correct some misconceptions and improve community awareness on abortion related issues community providers, including reproductive health agents and health extension workers can teach about availability of services and about abortion related complications.(6)
10 A cross sectional hospital based descriptive study in five hospitals of Addis Ababa was done to determine the primary abortionist while the patient is in hospital, the type of material used to terminate the pregnancy. This study was conducted on 1991 and published on East African Medical Journal on 2001. A total of 2275 cases of abortion had been identified and managed in the five hospitals. The study demonstrated that 984(43.3%) were spontaneous abortions .Of the 1290 illicit or unsafe abortions admitted by patients (certainly induced) in 455(35.3%) of the abortions were performed by the health assistant, 366(28.3%) self induced and 306(23.7%) by cleaners working in the operation theatre. In 744 (60%) of the abortions were carried out at the abortionist home while 452(35%) at the patients home. The remaining 94(5%) of the abortions were done safely in hospitals or doctors office by professionals. Another very important finding of this study was that the most commonly used method for inducing the abortion were in 417(32.3%) high dose of ampicillin per OS and 414(32.1%) by inserting plastic tubes (intravenous giving set) per vagina.(15) The issue of abortion clearly presents an enormous moral and ethical dilemma. The study results are very clear. While abortion is illegal or where services are not readily available and/or personnel are not well trained, unsafe abortion carries a high risk of complication, permanent damage resulting in infertility and even death. (15) One study Published Journal Pone October 11, 2010 estimated mortality risks for unsafe and medical abortion and childbirth for Tanzania and Ethiopia, and used a mathematical model for changes in maternal mortality that are achievable if unsafe abortion were replaced by medical abortion. The study focused on misoprostol-only regimens due to the drug’s low cost and accessibility Ethiopia and Tanzania were chosen for their high MMRatios, unsafe abortion case-fatality rates and proportions of maternal mortality attributable to unsafe abortion. These countries also provide interesting contrasts as they differ in important areas including abortion legislation (with Ethiopia’s law recently liberalized) and provision of health care services (Tanzania has higher access to antenatal care, contraception and health facility treatment for acute respiratory infection (ARI)). Additionally, both countries have recently licensed misoprostol for post-partum hemorrhage. Therefore access to medical abortion using misoprostol is a real possibility because such registration improves availability for obstetric-gynecologic conditions in general. (2) This study argues that thousands of lives could be saved each year in each country by implementing medical abortion using misoprostol. (2122 in Tanzania and 2551 in Ethiopia assuming coverage equals family planning services levels: 56% for Tanzania, 31% for Ethiopia). Universal medical abortion coverage reduces MMRatios by 13% from current estimates for both countries, with each 10% increase in coverage broadly conferring a 1.0–2.0% decrease.(2) This constitutes considerable progress towards MDG 5. If the higher estimates for Ethiopia’s abortion-attributable-maternal mortality are correct (35%), the universal availability of misoprostol could reduce Ethiopia’s MMRatio from 720 to 528, giving it a lower MMRatio than Bangladesh, a country 32 places above Ethiopia on the Human Development Index. Even assuming low abortion attributable- maternal mortality (3.9%), Ethiopia could save upwards of 6500 lives annually with universal access. (2)
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Conclusion -
Unsafe abortion is a serious public health problem for both Ethiopia and Sub-Saharan Africa. Even though abortion laws become less-restrictive there is lack of awareness of the legal status. The international community considers unsafe abortion as a preventable major cause of maternal mortality and morbidity that can be reduced through organized efforts of governments, nongovernmental organizations and the health community. Women with low socio economic status and/ or living in rural areas have poor access of safe legal abortion hence are more likely to suffer adverse outcomes of unsafe abortion. Research on unsafe abortion can affect policy and program positively.
Recommendation Capacity building of health facilities, training of health professionals to provide safe abortion, provision of accessible legal safe abortion service, post abortion care and family planning counseling are very likely to improve the magnitude and severity of adverse outcome of unsafe abortion.
Limitation of the review Personally one major challenge I faced in writing this review is; Most Journals found and available by computerized libraries such as HINARI/PubMed Advanced Searching require payment with foreign currency. Most of the ideas I used for writing for Limitation of this review are taken from similar review article on Complications of unsafe abortion in sub-Saharan Africa conducted by The Commonwealth Regional Health Community Secretariat in 1994 .Since reputable organizations and concerned countries ( 'PAS, Carrboro, USA, Johns Hopkins Program for International Education in Reproductive Health, Baltimore, USA and Commonwealth Regional Health Community Secretariat for East, Central and Southern Africa, Arusha, Tanzania) are involved ,they can provide a wider view on the issue. Below are most of their views modified with scope of my review. The most glaring gap in the epidemiological research is the lack of knowledge about the magnitude of abortion complications at the population level; specifically, the number of women who do not seek care in public facilities because: Community-based studies should be conducted to complement the wealth of hospital-based data in order to gain a clearer picture of the true magnitude of unsafe abortion complications in the region. Research on long-term consequences of unsafe abortion (e.g. chronic disabilities) and on special populations (e.g. adolescents, HIV positive women) is needed. No studies report on pain control and perceptions of pain from the woman's point of view. Clinical studies on antibiotic therapies for incomplete abortion patients is one area of recommended focus,
12 The infrastructural, personnel and follow-up requirements for providing induced abortion services (whether using MVA, sharp curettage, or mifepristone), where legally indicated, should be evaluated so that safe, high-quality abortion services can be expanded. There is sacristy of literature on the cost of treating abortion complications Investigations should examine system-wide resources expended, including an analysis of opportunity costs (e.g. longterm productivity losses due to morbidity and mortality from unsafe abortion). The definition of cost should be expanded to include measurements of the psycho-social and economic costs to families and communities as a result of abortion-related maternal deaths and disabilities. In addition, cost-benefit analyses of interventions are needed; for example, cost savings from the introduction of post-abortion family planning or liberalization of the laws (which would hypothetically decrease the number of late and complicated abortions) could be examined. Future hospital-based operations research is crucial in order to identify the most effective ways to link emergency treatment of abortion complications and family planning programs. In addition, the relationship between abortion and contraception over time has not been well examined. Studies on males as partners, providers, and decision makers are also grossly lacking. Understanding males as partners - specifically in terms of the decision to seek an abortion, the level of emotional and economic support offered to women seeking an abortion is crucial . Analyses of the feasibility of legal reform in a variety of political, cultural, and religious settings, and studies on the impact of other reproductive health laws and policies on women who seek abortions should be conducted.
Reference 1. Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008 Sixth edition, WHO Library Cataloguing-in-Publication Data 1 2. The Potential of Medical Abortion to Reduce Maternal Mortality in Africa: What Benefits for Tanzania and Ethiopia? PLoS ONE 5(10): e13260. doi:10.1371/journal.pone.0013260 2 3. UNSAFE ABORTION AND MATERNAL MORTALITY: IS AFRICA PREPARED TO FACE THE REALITY? EAST AFRICAN MEDICAL JOURNAL February 2004 3 4. Facts on Unintended Pregnancy and Abortion in Ethiopia ;Alan Guttmacher Institute (AGI) www.guttmacher.org 4 5. Unsafe abortion: the preventable pandemic* Lancet_4,WHO 5 6. Utilization of post-abortion care services in three regional states of Ethiopia [Ethiop. J. Health Dev. 2010;24 Special Issue 1:123-129] 6 7. HOW RESEARCH CAN AFFECT POLICY AND PROGRAMME ADVOCACY: EXAMPLE FROM A THREE-COUNTRY STUDY ON ABORTION COMPLICATIONS IN SUB-SAHARAN AFRICA East African Medical Journal Vol. 81 No. 2 February 2004 7 8. Complications of unsafe abortion in sub-Saharan Africa, heapol.oxfordjournals.org using pubmed 8 9. Pregnancy Termination in Sub-Saharan Africa: The Need for Refined Data International Journal Of Health Research Peer-reviewed Online Journal http://www.ijhr.org 9 10. The Estimated Incidence of Induced Abortion In Ethiopia,2008, International Perspectives on Sexual and ReproductiveHealth,2010,36(1):16–25. 10
13 11. Caring forWomenwith Abortion ComplicationsIn Ethiopia:National Estimates and Future Implications International Perspectives on Sexual and ReproductiveHealth, 2010,36(1):6–15 11 12. Responding to Unsafe Abortion in Ethiopia; A Facility-based Assessment of Postabortion Care Servicesin Public Health Sector Facilities in Ethiopia 12 13. The potential role of the private sector in expanding post abortion care in Addis Ababa ,Amhara and Oromia regions of Ethiopia,Ethiop.J. Health Dev.2003;17(3):157-165 13 14. Quality of post-abortion care in public health facilities in Ethiopia [Ethiop.J.Health Dev. 2008;22 (1):26-33] 14 15. Illegal abortion in Addis Ababa Ethiopia ;East African Medical Journal Vol 78 No.1 January 2001 15 16. Developments in laws on induced abortion: 1998-2007. International Family Planning Perspectives, 2008, 34(3):110-120. 17. Abortion Worldwide: a decade of uneven progress. New York, Guttmacher Institute, 2009. 18. The Millennium Development Goals Report. New York 2008. http://www.un.org/millenniumgoals/ 19. WHO analysis of causes of maternal death: a systematic review. Lancet 367: 1066– 1074 20. Sharing Responsibility: Women, Society and Abortion Worldwide. The Alan Guttmacher Institute (1999) New York. Available: http://www.guttmacher.org/ pubs/sharing.pdf 21. Reducing Unplanned Pregnancy and Abortion in Zimbabwe through Post Abortion Contraception. Studies in Family Planning. 2002; 33(2). 22. McKay, H.E., Rogo, K.O. and Dixon, D.B. FIGO society survey: acceptance and use of new ethical guideline regarding induced abortion for non-medical reasons. Inter. J. Gyne. Obstet. 2001; 75:327-336
