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Research
The magnitude and severity of abortion-related morbidity in settings with limited access to abortion services: a systematic review and meta-regression
  1. Clara Calvert1,
  2. Onikepe O Owolabi2,
  3. Felicia Yeung3,
  4. Rudiger Pittrof4,
  5. Bela Ganatra5,
  6. Özge Tunçalp5,
  7. Alma J Adler6,
  8. Veronique Filippi7
  1. 1 Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
  2. 2 Guttmacher Institute, New York, USA
  3. 3 School of Medicine, King’s College London, London, UK
  4. 4 Guy’s and St Thomas’ NHS Foundation Trust, London, UK
  5. 5 Department of Reproductive Health and Research, WHO, Geneva, Switzerland
  6. 6 Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
  7. 7 Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Dr Clara Calvert; clara.calvert{at}lshtm.ac.uk

Abstract

Introduction Defining and accurately measuring abortion-related morbidity is important for understanding the spectrum of risk associated with unsafe abortion and for assessing the impact of changes in abortion-related policy and practices. This systematic review aims to estimate the magnitude and severity of complications associated with abortion in areas where access to abortion is limited, with a particular focus on potentially life-threatening complications.

Methods A previous systematic review covering the literature up to 2010 was updated with studies identified through a systematic search of Medline, Embase, Popline and two WHO regional databases until July 2016. Studies from settings where access to abortion is limited were included if they quantified the percentage of abortion-related hospital admissions that had any of the following complications: mortality, a near-miss event, haemorrhage, sepsis, injury and anaemia. We calculated summary measures of the percentage of abortion-related hospital admissions with each complication by conducting meta-analysis and explored whether these have changed over time.

Results Based on data collected between 1988 and 2014 from 70 studies from 28 countries, we estimate that at least 9% of abortion-related hospital admissions have a near-miss event and approximately 1.5% ends in a death. Haemorrhage was the most common complication reported; the pooled percentage of abortion-related hospital admissions with severe haemorrhage was 23%, with around 9% having near-miss haemorrhage reported. There was strong evidence for between-study heterogeneity across most outcomes.

Conclusions In spite of the challenges on how near miss morbidity has been defined and measured in the included studies, our results suggest that a substantial percentage of abortion-related hospital admissions have potentially life-threatening complications. Estimates that are more reliable will only be obtained with increased use of standard definitions such as the WHO near-miss criteria and/or better reporting of clinical criteria applied in studies.

  • maternal health
  • systematic review

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjgh-2017-000692

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    Footnotes

    • Handling editor Seye Abimbola

    • Contributors VF, BG and ӦT initiated the study and defined the initial research question. CC, OOO and FY developed the detailed methodology and carried out the literature review. CC drafted the protocol, analysed the data and drafted the manuscript. VF reviewed any doubtful papers. AJA assisted with the integration of data from the previous systematic review. FY and RP helped with the extraction of clinical data from included studies. All other authors critically reviewed the draft and approved the final version for publication.

    • Funding This work was primarily funded by the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored program executed by the World Health Organization (WHO). We also acknowledge the support from the Strengthening Evidence for Programming on Unintended Pregnancy (STEP UP) funded by the Department for International Development (DFID) which co-funded VF and OO’s time for this review.

    • Competing interests None declared.

    • Patient consent Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data are available.