Unsafe abortion is a major cause of maternal death, and the only one that is completely preventable. Yet over 30 million unsafe abortions occur each year, leading to at least 29,000 deaths and millions of serious complications—nearly all in low- and middle-income countries. MSF teams see these tragic consequences first-hand, treating thousands of patients every year with severe, potentially life-threatening effects from unsafe abortion.
To mark International Safe Abortion Awareness Day (28 September 2024), this Collection presents highlights of MSF’s work on safe abortion care (SAC) as a way to reduce maternal death and injury. By re-assessing and reshaping how our projects deliver SAC in fragile and conflict-affected settings, we have been able to significantly expand services in those contexts and across MSF projects globally. In parallel, we also conducted in-depth studies of abortion complications and their contributing factors in fragile settings, where a dearth of evidence limits understanding of women's needs in accessing comprehensive care. These findings are helping to identify gaps in service delivery and inform operational decision-making.
BACKGROUND
Abortion-related complications remain a main cause of maternal mortality. There is little evidence on the availability and quality of post-abortion care (PAC) in humanitarian settings. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR).
METHODS
We mapped indicators corresponding to the eleven domains of the WHO Maternal and Newborn Health quality-of-care framework to assess inputs, processes (provision and experience of care), and outcomes of PAC. We measured these indicators in four components of a cross-sectional multi-methods study: 1) an assessment of the hospitals’ PAC signal functions, 2) a survey of the knowledge, attitudes, practices, and behavior of 140 Nigerian and 84 CAR clinicians providing PAC, 3) a prospective review of the medical records of 520 and 548 women presenting for abortion complications and, 4) a survey of 360 and 362 of these women who were hospitalized in the Nigerian and CAR hospitals, respectively.
RESULTS
Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26 in the CAR hospital. In both hospitals, less than 2.5% were treated with dilatation and sharp curettage. Over 80% of women received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients with no documented indication. Among discharged women in CAR, 99% received contraceptive counseling but only 39% did in Nigeria. Over 80% of women in Nigeria reported positive experiences of respect and preservation of dignity. Conversely, in CAR, 37% reported that their privacy was always respected during examination and 62% reported short or very short waiting time before seeing a health provider. In terms of communication, only 15% felt able to ask questions during treatment in both hospitals. The risk of abortion-near-miss happening ≥ 24h after presentation was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time.
CONCLUSIONS
Our comprehensive assessment identified that these two hospitals in humanitarian settings provided lifesaving PAC. However, hospitals need to strengthen the patient-centered approach engaging patients in their own care and ensuring privacy, short waiting times and quality provider-patient communication. Health professionals would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.
The first delay (from the onset of symptoms of the pregnancy loss to the decision to seek care) was characterized by the duration of time it took to recognize the pregnancy and pregnancy loss in addition to religious beliefs that it is the will of a higher power that she lost the pregnancy. The second delay (from the decision to seek care to arriving at a place that could provide adequate care for her complication, i.e. the study site); was due to lack of money, lack of passable roads and transport, use of traditional healers, challenges being seen by providers at lower-level facilities, referrals not being facilitated and misdirection by healthcare providers. The third delay was not present in our results. No respondent said she knowingly interfered with the pregnancy; understanding why these pregnancy losses resulted in near-miss complications is critical to reducing maternal morbidity and mortality in Northern Nigeria. Addressing health literacy as well as social and financial barriers holds the potential to get women to care sooner and avert these near-miss or potentially life-threatening events.
A dearth of evidence on abortion complications in fragile settings limits the understanding of women’s needs in access to comprehensive abortion care in contexts like Jigawa state. This study describes the burden of abortion-related complications and their contributing factors in the maternity ward in an MSF-supported referral hospital in Jigawa state, Nigeria. This evidence brief presents selected results for three components of the AMoCo study (Abortion-related Morbidity and Mortality in Conflict-affected and Fragile Settings):
- A quantitative observational study of clinical characteristics of women presenting with any type of abortion complications,
- A quantitative survey with a sub-group of these women who were hospitalized, and
- A qualitative study among selected women with very severe complications (potentially life-threatening and near-miss complications).
Conducting abortion research in fragile settings presents challenges, many of which are present in other low-resourced settings to various degrees but when appearing all together, collectively served to create a set of barriers to collecting data that required creative adaptations to address and even then, we could not overcome all of them.
RESULTS
Challenges that we experienced in the course of this mixed methods research project included limited access to the study sites by research team members, research being delayed to prioritize life-saving priorities which must take precedence when resource constraints mean that both cannot be carried out, a population skeptical of participating in research due to having negative experiences with the state/other actors as well as due to being research-naïve, geographic and language constraints impacting participant recruitment because of the fact that people are coming from various displaced locations to a particular health facility, a low literacy population meant that they could not read the consent form and due to the stigmatized subject matter we did not want a family member consenting them, and respondents’ challenges participating around the time of discharge because respondents needed to travel home with family members.
CONCLUSIONS
These strategies are relevant not only to abortion research but also other research in resource-constrained/fragile and conflict-affected contexts. Improving the health of the most vulnerable can only be done through understanding barriers to care in insecure and challenging environments. Recommendations include to plan for offsite and long-distance training, supervision, and quality assurance; attempt to negotiate flexible timelines with donors; hire field staff whose only responsibility is data collection; where possible, find a way to include the most vulnerable members of the study population; adapt informed consent processes for low literacy populations; and consider including travel support for respondents. Iterating improvements in data collection innovations in these contexts will advance the field by spurring more research upon which to base policy and practices.
Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR).
METHODS
We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records’ reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity.
RESULTS
We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%).
CONCLUSION
Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.
Despite instituting a policy in 2004, Médecins Sans Frontières (MSF) continuously struggled to routinely provide safe abortion care (SAC). In 2016, the organization launched an initiative aimed at increasing availability of SAC in MSF projects and increasing understanding of abortion-related dynamics in humanitarian settings.
METHODOLOGY
From March 2017 to April 2018, MSF staff conducted support visits to 10 projects in a country in sub-Saharan Africa. Each visit followed a systematic approach with six key components and related tools that were later shared with teams worldwide. Data regarding women seeking abortion services and related outcomes were collected and analyzed retrospectively.
RESULTS
From Q1 2017 through Q4 2019, SAC provision increased significantly in all 10 projects, rising from three to 759 safe abortions per quarter. Teams received 3831 patients seeking SAC and provided 3640 first and second trimester abortions, over 99% via medication methods. The overall complication rate was 4.29% and 0.3% for severe, life-threatening complications. No major security incidents were reported. MSF provision of SAC worldwide increased from 781 in 2016 (the year before this initiative began) to 21,546 in 2019.
CONCLUSION
Implementation of SAC in humanitarian settings—even those with significant legal restrictions—is possible and necessary. Both first and second trimester medication abortion can be safely and effectively provided through both home- and facility-based models of care. Programmatic data provide valuable insights into abortion-related dynamics which must shape operational decision-making. Addressing internal barriers and providing direct field support were key to stimulating organizational cultural change.
Provision of safe abortion care: a multicentre descriptive mixed-methods analysis, MSF OCB 2018-2020
• The COVID-19 pandemic has begun to severely limit access to sexual and reproductive healthcare, including contraception and safe abortion care (SAC), which have historically not been regarded as essential health services.
• Shutdown or delays of contraception and SAC during COVID-19 will disproportionately impact the most vulnerable populations, including women and girls in low-income and middle-income countries, and lead to considerable and preventable death and lifelong disability.
• Médecins Sans Frontières calls on the global health community to strengthen access to contraception and SAC for populations everywhere, and especially in poor and crisis settings, by engaging with women and their communities to develop self-managed models of care.
