Abortion is the termination or initiation of termination ofpregnancy before reaching viability (before 20weeks or<500grams according to WHO or before 28 weeks ofgestation or less than 1kg fetal weight in Ethiopia andUK). Abortion is the expulsion of the fetus from the uterus before it is sufficiently developed. The most common time for abortion to occur is between 8 and 13 weeks into the pregnancy.
Types of abortion
Spontaneous abortion
Spontaneous abortion (also called a “miscarriage”) occurs without any deliberate or external manipulation to terminate the pregnancy.
Induced abortion
This is a deliberate termination of the pregnancy by mechanical or chemical means.Depending on the country, such acts of deliberately terminating a pregnancy can be illegal.
Therapeutic abortion
This is a deliberate termination of a pregnancy, which is a serious threat to the life of themother. Even in many countries where induced abortion is illegal, exceptions are made toallow therapeutic abortions.
Unsafe abortion
An unsafe abortion is any abortion (legal or illegal) performed under conditions that represent a threat to the health of the pregnant woman. Generally an abortion is considered unsafe when it is performed by an untrained (or poorly trained) person or using dirty instruments in unclean surroundings. An unsafe abortion carries with it a number of risks, which are discussed in greater detail below.
Magnitude of Abortion
Each year women around the world experience 80 million unwanted pregnancies. Out of these mothers, nearly 42 million decide to have an abortion and about 20 million of them undergo unsafe abortion.About Fifteen percent of all clinically recognizable pregnancies end in spontaneous abortions. It is estimated that 30 to 50 million induced abortions are performed annually in the world and about half of these are performed illegally.
In Ethiopia it is estimated that there are 3.27 million pregnancies every year of which approximately 500,000 end in either spontaneous or unsafely induced abortion. WHO characterizes unsafe abortion by the lack of skilled providers, safe techniques, and/or sanitary facilities. Unsafe abortion is the commonest cause of maternal mortality accounting for up to 32% of all maternal deaths in Ethiopia.
Magnitude of Abortion in Ethiopia
Accurate estimates are difficult to get, but it is clear that abortion is widespread and generally performed by untrained persons. It is the leading cause of maternal mortality. In a community-based study, abortion accounted for 54.2 % of the direct causes of maternal deaths. It is one of the top ten causes of admissions among women. Unsafe abortion accounts for nearly 60 % of all gynecologic admissions and almost 30 % of all obstetric and gynecologic admissions. In a study done in Addis Ababa; abortion hospital occupancy rate among mothers was 32. 2 %.
Causes of Abortion
A young woman may decide to terminate the pregnancy because,
· She wants to continue with her education. In many countries where abortion laws are restrictive, girls can be expelled from school as soon as the pregnancy is discovered. (It is worth noting that the man or boy responsible for the pregnancy usually goes unpunished).
· She does not want to bring shame to her family. In many communities in Africa, pregnancy before marriage is treated withshame and as evidence of poor parenting - a judgment many mothers andfathers cannot live with.
· She may be abandoned by her husband, boyfriend or partner
· She is a victim of rape or defilement or incest and does not want to prolong heragony by bringing the pregnancy to term.
· She lacks support during pregnancy.
A woman's decision to get an abortion is not made in a vacuum, but is bound up in society's feelings aboutabortion as well as her feelings about the pregnancy:
v Several social factors influence the emotional decision of obtaining abortion. The cultural attitudes toward family size also influence woman’s perception of abortion. When large families are the norm, she is viewed as, at best, odd. However, as norms change and children become more of an economic burden, this should remove another source of external pressure.
v Religious attitudes strongly affect the decision
v Personal and interpersonal reasons for continuing the pregnancy can be a great source of conflict. Often, pregnancy is the unwanted byproduct of wanted s*exual relations, while a pregnancy that is desired to prove her ability as a woman may have little relationship to desire for the actual child.
v Age and martial status are important factors inthe decision along with number of other children already born. In some instances abortion is the first responsible decision the woman has made, and often the effect is beneficial to other children in a large family or to the woman planning an unwise marriage. Counseling helps the outcome. A large benefit of legalized abortion is the opportunity to talk with a trained counselor. Unsafe abortion is a public health problem, particularly among young women since:
v Poor access to family planning information and services →unplanned pregnancy
v They are less likely than older women to have the social contacts and financial means to obtain a safe abortion
v Young women are more likely to delay seeking help and hence seek terminations at more advanced stages of gestation when the risks of morbidity and mortality are higher.
Prevention unsafe abortions
What can be done about unwanted pregnancies and unsafe abortions?
· Ensure universal access to family planning
· Increase the availability of safe abortion services to the extent allowed by law
· Improve the quality and accessibility of post-abortion care
· Educate communities about reproductive health and unsafe abortion; and
· Work for changes in policies to safeguard women’s reproductive health.
Providing high quality appropriate services
In more than 131 developing countries, induced abortion is permitted in certain circumstances. In countries where abortion is legal:
· Services should be safe and available
· Service providers must be carefully trained to offer high quality services and compassionate counseling.
· Providers must be well-informed about the legal status of abortion and protocols for providing services, so that women who are eligible can access services quickly and without unnecessary delays or bureaucratic procedures.
Available services should also be publicized within thecommunity and links should be strengthened withwomen’s groups, health centers and related organizations to ensure that women who need services are informed about where and when to seek care. Appropriate technologies such as vacuum aspiration should be available. New technologies, such as nonsurgical abortion, should be made available, where appropriate and feasible.
Offering post-abortion care
Whatever the legal status of abortion, high qualityservices for treating and managing complications ofabortions should be accessible to all women to reducerelated maternal death. The recently promoted abortioncare approach is women-centered approach of provisionof the services. In the woman –centered approach, theprovider asks for and focuses on woman’s concerns andinterests and takes a comprehensive approach tomeeting every woman’s medical and psychologicalneeds at the time of treatment.
Key elements of post abortion care include:
Treatment of incomplete and unsafe abortion;
Counseling;
Family planning services;
Links to comprehensive reproductive health services; and
Community and service provider partnerships.
Educating communities
Education is critical for reducing the public health problem of unsafe abortion. Health education messages should be based on the incidence and impact of unsafe abortion within communities, and be sensitive to people’s beliefs, attitudes and practices. They should offer information on: the legal status of abortion; preventing unwanted pregnancy; avoiding unsafe abortion; and recognizing and seeking appropriate treatment for abortion complications.
Supportive laws and policies
When laws are modified to allow greater access to abortion-related services, such as legal changes, must be accompanied by changes in the health service structure.
· Development of appropriate service delivery standards; protocols, guidelines and administrative procedures;
· Restructuring of the health system to ensure that high quality, safe services are available at the lowest levels compatible with good quality care.
· Staff must be trained and willing to provide services; and
· Supplies of necessary equipment and drugs must be available
· Requisite funds must be allocated for all these activities.
Policies and laws can contribute to unsafe abortion by impeding women’s ability to protect their sexual and reproductive health.
Examples
· Prohibitions on contraceptive delivery to unmarried women and adolescents
Grounds on Which Abortion is Permitted, revised abortion law of Ethiopia, (House of Parliament,2005)
· When the pregnancy puts the woman’s life at risk
· Fetal impairment or deformity
· When pregnancy follows Rape or incest (based on the woman’s complaint only)
· When pregnancy occurs in minors (stated maternal age <18 years)
· The woman is physically and mentally unable to care for the would-be born child
Consequences of unsafe abortion
The consequences of and complications arising from unsafe abortion are multiple and may occur immediately or later. They can be categorized as medical, psychological, social and economic.
Risks associated with an unsafe abortion
Medical
Medical complications include,
· Infection (like sepsis)
· Hemorrhage (heavy bleeding)
· Injuries to tissues and organs
· Generalized infection in the blood stream (septicemia)
· Anaemia (due to loss of blood)
· Death
Psychological
Psychological consequences arising from unsafe abortion include,
· Depression
· Withdrawal and
· Sexual dysfunction
Note: Sometimes psychological problems may linger and require specialized care usually not available to adolescents because of the stigma attached to unmarried pregnancy.
Social
Social complication of unsafe abortion include,
· Dropping out of school
· Stigmatization (disgrace and dishonour)
· Rejection by the community
· Being forced to leave home
· Early marriage (often forced by parents)
· Poverty
· End of the relationship with the father of the child
Economic
Unsafe abortion has also economical impact including,
· Hospital costs (which may be enormous) and
· Impact of not being able to work or attend school