Elsevier

Contraception

Volume 70, Issue 4, October 2004, Pages 319-326
Contraception

Original research article
Determinants of maternal deaths in induced abortion complications in Ivory Coast

https://doi.org/10.1016/j.contraception.2004.04.011Get rights and content

Abstract

Persistently high levels of maternal mortality have been reported in Abidjan, the capital of Ivory Coast, with a high prevalence of deaths related to complications of induced abortion. In order to assess the determinants of maternal deaths in induced-abortion complications, this study investigated women admitted to the gynecological departments of four reference hospitals throughout Ivory Coast. Information concerning abortion events was collected by means of a questionnaire during a confidential, face-to-face interview. Medical records were used to collect clinical data and final vital status. In our series, 60% of women declared that they induced abortion themselves at their home; a large majority mentioned “insertion of objects into the vagina” or “ingestion of traditional plants” for this purpose. On the other hand, 40% declared that abortion had been performed by a health worker, mostly at a health facility and by using surgical methods (dilatation and curettage). Less-educated women were more likely to have chosen to induce abortion themselves at home, and more-educated women had undergone abortion through a health professional. Our findings highlight the role of both women and health professionals in responsibility for induced abortion complications.

Introduction

About 210 million pregnancies occur each year throughout the world. It has been estimated that 46 million of these pregnancies end in abortion: 36 million in developing countries and 10 million in developed countries. The World Health Organization (WHO) estimates that, worldwide, almost 20 million unsafe abortions take place each year, with 95% of these (19 million) performed in developing countries. About 80,000 maternal deaths per year are thought to be due to abortion complications, accounting for about 13% of all maternal deaths in the world, one in eight pregnancy-related deaths [1].

However, this global figure for abortion and its consequences masks large differences between regions and countries. In Africa, 5 million unsafe abortions are performed annually, resulting in an estimated 34,000 maternal deaths, a total very similar to that reported for Asia (38,500), except that twice the number of abortions (10 million) are performed in Asia. Thus, the maternal mortality ratio, corresponding to the risk of death due to unsafe abortion, may exceed 100/100,000 live births in Africa, whereas it is about 40/100,000 in Asia or in Latin America and less than 1/100,000 in the USA and Europe [2], [3].

Abortion is generally illegal or very restricted in Africa. This makes it difficult to estimate the frequencies of abortion complications and to describe abortion practices and abortion-related maternal deaths. Thus, data on these subjects are based on very few, limited studies. Some authors consider that abortion complications may account for a quarter, perhaps even a third, of all cases of maternal death in some African countries. In a review, Rogo suggested that at least 20% of maternal deaths in East and Central Africa could be attributed to abortion complications [4]. Similar figures have been published for a number of West African countries [5], [6].

In a review undertaken by the Commonwealth Regional Health Community Secretariat to document the magnitude of abortion complications in Commonwealth member countries, Benson et al. [7] observed that incomplete abortion patients represent a high proportion of all hospital gynecological admissions, with hemorrhage and sepsis being the most common complications.

Recently, Thonneau et al. [8] have demonstrated in a large multicenter African research study that complications of induced abortion may account for a third of all maternal deaths in African countries, and that previous WHO figures (15% of maternal deaths due to abortion complications) are certainly underestimated. Furthermore, qualitative data on abortion practices are very scarce. As stated by Barreto et al. [9] in a review of the subject, the consequences for women's health, the social and cultural context within which induced abortion is performed, and even the characteristics of women resorting to abortion are unknown. Detailed information on induced abortion practices is scarce because of its sensitive nature, and the stigma of abortion dictates the secrecy of the procedure [10]. Furthermore, the distinction between spontaneous and induced abortion is a major difficulty in all studies conducted in this field. Intentional error, where respondents lie or refuse to disclose the fact they have had an abortion, is very common and easily understandable in countries where induced abortion is socially unacceptable and also punishable.

Ivory Coast is considered to be one of the most advanced countries in West Africa. However, abortion is prohibited and punished under criminal law (based on the old French law dating from 1920) except in cases of immediate risk to the physical and mental health or the life of the woman. In 1996, persistently high levels of maternal mortality were reported in Abidjan, the capital of Ivory Coast, with a high prevalence of deaths related to complications of induced abortion [11]. By analyzing maternal deaths due to complications of induced abortion and registered in one reference hospital in Abidjan, we found that among all indigenous abortifacients reported by women, ingestion of plants carries the highest risk of death [12].

The objectives of this multicenter prospective study conducted in Ivory Coast were to describe various abortion practices and to assess their consequences on maternal mortality.

Section snippets

Sites

From 1998 to 2001, the Research Division of the European Union carried out a series of studies on first-trimester obstetric complications (spontaneous abortion, induced abortion and ectopic pregnancy) in West and Central Africa. This project was conducted by two European teams (Human Fertility Research Group, Toulouse, France; Anthropology Unit, Oslo, Norway) and several teams of African researchers and clinicians, working within a French-language research network on reproductive health.

As part

Results

During the 6 months of the study period, 2056 women were admitted for first-trimester obstetric complications, i.e., complications of spontaneous abortion, complications of induced abortion, ectopic pregnancy or molar pregnancy. In this current study, we excluded women diagnosed with spontaneous abortion (n = 1019), women admitted for ectopic pregnancy (n = 489) and those with a diagnosis of molar pregnancy (n = 59). For some women (n = 32), it was impossible to determine whether the abortion

Discussion

The first finding of our study is the surprisingly similar induced abortion fatality rate in women whose abortion had been performed by a health worker and in those who had induced abortion themselves (5.0% vs. 5.4%, NS). Obviously, we are unaware of the overall total number of abortions in these African sites and the percentage of abortion complications; nor are we able to estimate the distribution of abortion complications between those performed by the women herself and those performed by

Conclusion

Our findings highlight the weight of complications of induced abortion in maternal deaths, and also probably the role of both women and health professionals in responsibility for induced abortion complications. This conclusion was presented in detail to our African colleagues at the last annual meeting of the African Society of Gynaecology and Obstetrics, and the findings initiated an exhaustive discussion of the issue. Faced with this dramatic problem of maternal health, it is becoming

Acknowledgements

Financial and technical supports have been provided by the Ministry of Health of Ivory Coast, the European Union (DG XII), the French Ministry of Foreign Affairs, the CECOS Midi-Pyrenees, the INSERM (French National Institute of Health and Medical Research) and by the Human Fertility Research Group (Toulouse, France).

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