Magnitude and severity of abortion-related complications and factors associated with severe and near miss events in African humanitarian settings

What did the study set out to achieve?

The study aimed to describe and estimate the burden of all post-abortion complications, particularly severe complications, near-miss complications and deaths, and factors associated with severe morbidity among women admitted for post-abortion care (PAC) in Médecins Sans Frontières (MSF) facilities in Africa.

The locations of Bangui in the Central African Republic (CAR), Jahun in Nigeria and Masisi in the Democratic Republic of Congo (DRC) were chosen as having one large MSF-supported maternity center located and being a humanitarian (fragile or conflict-affected) setting. Given challenges related to Ebola, COVID-19 and insecurity the study team revised this from a 3-country prospective record review and mixed method observational study design, to a full study in Nigeria and CAR, and a limited off-site study, in DRC, using learning from the first two sites, to conduct retrospective record reviews.

What were the findings?

The research generated evidence highlighting the magnitude and severity of abortion-related complications and provided details on the trajectories that led women to experience severe and near-miss abortion-related complications in the humanitarian settings of CAR and Nigeria. The research also highlighted the challenges and barriers to health care experienced by women seeking PAC in these settings.

• Over 500 women were included in the study from each hospital setting. In the CAR hospital, abortion complications constituted nearly 19.9% of all pregnancy-related admissions; it was lower in the Nigerian hospital (4.2%).
• Severity of abortion-related complications was high: over 50% of complications in the CAR hospital and over 65% in the Nigerian hospital were severe.
• In the Nigerian hospital, 1 in 4 women interviewed reported having tried to induce their abortion. In the CAR hospital, the figure was nearly 1 in 2, many
  resulting in very severe or life-threatening complications. In both settings, most women had used unsafe methods to induce their abortions.
• There was diversity in abortion attitudes and gaps in knowledge and practice related to abortion care. A low level of knowledge about WHO-recommended medication abortion regimens was observed.
• There were a range of delays in care-seeking with many women taking days to reach care after the onset of symptoms. Pathways to care were complex. Barriers to accessing care included difficulties in navigating the health care system and a lack of referral pathways.

What does this mean for practitioners and policymakers?

The need is high for greater access to high quality contraception, safe abortion care, and post-abortion care to prevent and manage complications of abortion in fragile and conflict-affected settings. Addressing this challenge should be a high priority for donors and public health actors to reduce maternal morbidity and mortality in fragile and conflict-affected settings.

Preventing and managing underlying chronic health conditions like malnutrition and chronic anemia may reduce the lethality of abortion complications.

Attention may be needed to strengthen health services and capacities of health professionals to provide quality post-abortion, contraceptive and safe abortion care, and to improve pathways to care; recognising the complex social, cultural and legal issues that can constrain policymaking and investments for this care, in particular safe abortion and contraceptive services.

In June 2023 the team received follow on funding from the R2HC to conduct further uptake and impact activities, building on the study finding that a lack of public awareness of pathways to healthcare for abortion is a key barrier to improved health outcomes. A focused intervention targeting local and national mass media with the results of this study from CAR was conducted. At this 3-day workshop journalists were sensitized to the study concepts related to maternal mortality and morbidity, unsafe abortion, abortion legality and terminology. Many of the journalists shared outputs related to the workshop topics, and were inspired to keep talking about the issues related to abortion and sexual and reproductive health so that actionable messages reach women, girls and community healthcare actors.  They aim to set up a network to stay connected on this.

Banner photo credit: Samuel Sieber/MSF.