unsafe abortion case study

• Case report
• Open access
• Published: 14 June 2019

“Regardless, you are not the first woman”: an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua

• Samantha M. Luffy 1 ,
• Dabney P. Evans   ORCID: orcid.org/0000-0002-2201-5655 1 &
• Roger W. Rochat 1  

BMC Women's Health volume  19 , Article number:  76 ( 2019 ) Cite this article

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Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, public health practicioners and human rights advocates have made great strides to advance our understanding of sexual and reproductive rights and how they should be protected. The overall aim of the study was to understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua, from June to July 2014.

Case presentation

This case study focuses on the story of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her case, detailed under the pseudonym Ana Maria, presents unique challenges related to the fulfillment of sexual and reproductive rights due to the restrictive social norms related to sexual health, ubiquitous violence against women (VAW) and the total ban on abortion in Nicaragua. The case also provides a useful lens through which to examine individual sexual and reproductive health (SRH) experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; this in-depth analysis identifies the contextual risk factors that contributed to Ana Maria’s experience.

Conclusions

Far too many women experience their sexuality in the context of individual and structural violence. Ana Maria’s case provides several important lessons for the realization of sexual and reproductive health and rights in countries with restrictive legal policies and conservative cultural norms around sexuality. Ana Maria’s experience demonstrates that an individual’s health decisions are not made in isolation, free from the influence of social norms and national laws. We present an overview of the key risk and contextual factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion.

Peer Review reports

Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, however, the international community, States, and advocates have made great strides to advance our understanding of sexual and reproductive rights and how they can be protected at the national and international levels. The 1994 Cairo Declaration began this process by including sexual health under the umbrella of reproductive health and recognized the impact of violence on an individual’s sexual and reproductive health (SRH) decision-making. [ 1 ] One year later, the 1995 Beijing Platform for Action specifically addressed the issues of unintended pregnancy and abortion by emphasizing that improved family planning services should be the main method by which unintended pregnancies and unsafe abortions are prevented. [ 2 ]

A recent World Health Organization (WHO) report on the relationships between sexual health, human rights, and State’s laws sets the foundation for our contemporary understanding of these issues. The 2015 report describes sexual health as, “a state of physical, emotional, mental and social well-being in relation to sexuality.” [ 3 ] That state includes control over one’s fertility via access to health services such as abortion; it also includes the right to enjoy sexual experiences free from coercion, discrimination, and violence. [ 3 ] Whether experienced alone or in combination, rape, unintended pregnancy, and abortion are important SRH issues on which public health can and should intervene.

In the public health field, case studies provide a useful lens through which to examine individual women’s sexual and reproductive health experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; an in-depth analysis of these personal experiences can identify contextual risk factors and missed opportunities for public health rights-based  intervention. This type of analysis is especially cogent when legal policies and social factors, such as gender inequality, may influence one’s SRH decision-making process. On an individual level, bearing witness to women’s stories through in-depth interviews helps document their lived experience; surveying these experiences within the context of laws related to SRH provides important evidence for the impact of such policies on women’s well-being.

We present the case of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her complex experience of violence, unintended pregnancy, and unsafe abortion represent a series of contextual factors and missed opportunities for public health and human rights intervention. Ana Maria’s story, told through the use of a pseudonym, takes place in a city located in North Central Nicaragua – a country that presents unique challenges related to its citizens’ fulfillment of their sexual and reproductive health and rights.

Violence against women in Nicaragua

Along with 189 States, Nicaragua is a party to the United Nations (UN) Convention on the Elimination of All Forms of Discrimination against Women, which includes State obligations to protect and promote the health and well-being of Nicaraguan women. [ 4 ] As defined by human rights documents, the right to health includes access to health care services, as well as provisions for the underlying social determinants of health, such as personal experiences of structural violence. [ 5 ]

In the Nicaraguan context, political and sociocultural institutions support unequal power relations between genders. [ 6 ] Machismo is one such form of structural violence that perpetuates gender inequality and has been identified as a barrier to SRH promotion in Nicaragua. [ 7 , 8 ] The term ‘ machismo ’ is most commonly used to describe male behaviors that are sexist, hyper masculine, chauvinistic, or violent towards women. [ 9 ] These behaviors often legitimize the patriarchy, reinforce traditional gender roles, and are used to limit or control the actions of women, who are often perceived as inferior. [ 10 ]

The vast majority (89.7%) of Nicaraguan women have experienced some form of gender-based violence  during their lifetime, which poses a serious public health problem. The latest population-based Demographic and Health Survey showed that at least 50% of Nicaraguan women surveyed had experienced either verbal/psychological, physical, or sexual violenceduring their lifetime. An additional 29.3% of women reported having experienced both physical and sexual violence at least once, while another 10.4% reported having experienced all three types of violence. [ 11 ]

In 2012, Nicaragua joined a host of other Central and South American countries that have implemented laws to eliminate all forms of violence against women VAW, including rape and femicide. [ 12 ] Nicaragua’s federal law against VAW, Law 779, intends to eradicate such violence in both public and private spheres. [ 13 ] On paper, Law 779 guarantees women freedom from violence and discrimination, but it is unclear if the law is being adequately enforced; it has been reported that some women believe VAW has increased since the law’s implementation. [ 14 ]

Before Law 779, violent acts like rape, particularly of young women ages 15–24, were endemic in Nicaragua. Approximately two-thirds of rapes reported in Nicaragua between 1998 and 2008 were committed against girls under 17 years of age; most of these acts were committed by a known acquaintance. [ 15 ] Due to a lack of reporting and to culturally propagated stigma regarding rape, no reliable data suggest that Law 779 has been effective in reducing the incidence of rape in Nicaragua. For women who wish to terminate a pregnancy that resulted from rape, access to abortion services is vital, yet completely illegal. [ 16 ] In contrast, technical guidance from the WHO recommends that health systems include access to safe abortion services for women who experience unintended pregnancy or become pregnant as a result of rape. [ 17 ]

Family planning and unintended pregnancy in Nicaragua

Like violence, unintended pregnancies -- not only those that result from rape -- pose a widespread public health problem in Nicaragua. National data suggest that 65% of pregnancies among women ages 15–29 were unintended. [ 11 ] Oftentimes, unintended pregnancy results from a complex combination of social determinants of health including: low socioeconomic status (SES), low education level, lack of access to adequate reproductive health care, and restrictive reproductive rights laws. [ 18 , 19 , 20 ] Nicaraguan women of low SES with limited access to family planning services are at an increased risk of depression, violence, and unemployment due to an unintended pregnancy. [ 19 , 20 ]

The UN Committee on the Elimination of all forms of Discrimination Against Women (CEDAW) has expressed concern regarding the lack of comprehensive sexual education programs, as well as inadequate family planning services, and high rates of unintended pregnancy throughout Nicaragua. [ 21 ] Due to a lack of sexual education, Nicaraguan adolescents, if they use contraceptives like male condoms or oral contraceptive pills, often do so inconsistently or incorrectly. [ 22 ]

Deeply rooted cultural stigma surrounding unmarried women’s sexual behavior contributes to the harsh criticism of young women in Nicaragua that use a method of family planning or engage in sexual relationships outside of a committed union. [ 18 , 22 ] Also, young women who are not in a formal union may experience unplanned sex (consensual or nonconsensual) and are unlikely to be using contraception, which further increases the risk of unintended pregnancy. [ 22 ] These social and cultural factors, in conjunction with restrictive reproductive rights laws, may contribute to a high incidence of unintended pregnancy among young Nicaraguan women.

The total ban on abortion in Nicaragua

Compounding the economic, social, and emotional burden of unintended pregnancy on women’s lives is the current prohibition of abortion in Nicaragua. In 2006, the National Assembly unanimously passed a law to criminalize abortion, which had been legal in Nicaragua since the late 1800s. [ 20 ] Researchers often refer to this law as the “total ban” on abortion. [ 20 , 23 ] The total ban prohibits the termination of a pregnancy in all cases, including incest, rape, fetal anomaly, and danger to the life of the woman. Laws that prohibit medical procedures are, by definition, barriers to access; equitable access to safe medical services is a critical element of the right to health. [ 3 , 5 ] The UN Committee on Civil and Political Rights (CCPR) has also recognized the discriminatory and harmful nature of criminalizing medical procedures that only women undergo. [ 24 ]

Nicaragua is one of the few countries in the world to completely ban abortion in all circumstances. In States where illegal, abortion does not stop. Instead, women are forced to obtain abortions from unskilled providers in conditions that are often unsafe and unhygienic. [ 25 ] Unsafe abortions are among the main preventable causes of maternal morbidity and mortality worldwide and can be avoided through decriminalization of such services. [ 26 ]

The Nicaraguan ban includes serious legal penalties for women who obtain illegal abortions, as well as for the medical professionals who perform them, which can have profound negative effects on women’s health. [ 20 , 23 ] Women who need or want an abortion face not only the health risks that accompany an unsafe procedure, but additional criminal penalties. The total ban on abortion violates the human rights of both health care providers and women nationwide, as well as the confidentiality inherent in the patient-provider relationship. [ 20 ] It also results in a ‘chilling effect’ where health care providers are unwilling to provide both abortion and postabortion care (PAC) services for fear of prosecution. [ 20 ]

In response to the negative impacts of the total ban on maternal morbidity and mortality in Nicaragua, as well as detrimental effects on women’s physical, mental, and emotional health, CEDAW has recommended that the Nicaraguan government review the total ban and remove the punitive measures imposed on women who have abortions. [ 21 ] While the Nicaraguan government may not view abortion as a human right per se, women should not face morbidity or mortality as a result of illegal or unsafe abortion. [ 27 ]

Criminalizing abortion also increases stigma around this issue and significantly reduces people’s willingness to speak openly about abortion and related SRH services. Qualitative research conducted in Nicaragua suggests that women who have had unsafe abortions rarely discuss their experiences openly due to the illegal and highly stigmatized nature of such procedures. [ 18 ] Therefore, the overall aim of the study was to better understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua from June to July 2014. This private method of data collection allowed for the detailed exploration of each young woman’s personal experience with an unintended pregnancy, including the decision-making process she went through regarding how to respond to the pregnancy. Given the personal nature of this experience – including the criminalization and stigmatization of women who obtain abortions – IDIs allowed the participants to share intimate details and information that would be inappropriate or dangerous to share in a group setting. One case, presented here, emerged as salient for understanding the intersections of violence, unintended pregnancy, and abortion – and the missed opportunities for rights-based public health intervention.

Emory University’s Institutional Review Board ruled the study exempt from review because it did not meet the definition of “research” with human subjects as set forth in Emory policies and procedures and federal rules. Nevertheless, procedural steps were taken to protect the rights of participants and ensure confidentiality throughout data collection, management, and analysis. The first author reviewed the informed consent form in Spanish with each participant and then acquired each participant’s signature and verbal informed consent before the IDIs were conducted. The investigators developed a semi-structured interview guide with open-ended questions and piloted the guide twice to improve the cultural appropriateness of the script (Additional file 1 ). The investigators also collaborated with local partners to design and implement the research according to local cultural and social norms. Due to the contentious topics discussed in this study, these collaborators prefer to not be mentioned by name. Interviews were conducted in Spanish in a private location and audio taped to protect the participants’ privacy. Recordings were transcribed verbatim and transcripts were coded and analyzed using MAXQDA11 software (VERBI GmbH, Berlin, Germany).

Initially, participants were recruited for interviews through purposive sampling of individuals who had disclosed a personal experience with unintended pregnancy during focus group discussions (FGDs) conducted in a larger parent study. At the end of each interview, participants were asked to refer other young women they knew who may have experienced an unintended pregnancy to participate in an interview. This form of respondent-driven sampling created a network of participants with a wide variety of experiences with unintended pregnancy. Of the ten interviewees, two had experienced unintended pregnancy as a result of rape, though both used the phrase “ sexo no consensual ” or “nonconsensual sex” in lieu of “ violación, ” the Spanish word for rape. One of these women shared her personal experience receiving an unsafe abortion to terminate an unintended pregnancy that had resulted from rape. Her story, shared under the use of the pseudonym Ana Maria, is presented here in order to:

Illustrate the harmful impact of restrictive abortion laws on the health and well-being of women – especially those who do not have access to abortion in the case of rape; and

Exemplify the nexus of contextual risk factors that impact women’s SRH decision-making, such as conservative social norms and restrictive legal policies.

Through thorough analysis, we examine the impact of these contextual factors that impacted Ana Maria’s experience.

When she was 19, Ana Maria was raped by her godfather, a close friend of her family.

In an in-depth interview, Ana Maria described enduring incessant verbal harassment from her godfather – her elder brother’s best friend – in the months before the assault. He constantly called and texted her cell phone in order to interrogate her about platonic relationships with other men in town and to convince her to spend time alone with him. Even though he was married with children and she repeatedly dismissed his advances, he continued to engage in this form of psychological violence with his goddaughter. Ana Maria described eventually “giving in” and meeting him – not knowing that this encounter would result in her forcible rape.

The disclosure of Ana Maria’s rape during her interview was spontaneous and unexpected. Ana Maria was unwilling to disclose explicit details of the sexual assault. Instead, she stated multiple times that the sexual contact was nonconsensual and she did not want to have sex with him. When asked if she told anyone about this experience, she said no because she did not want others to judge her for what had happened.

Approximately a month of scared silence after she was raped, Ana Maria noticed that her period had not come. Nervous, she bought a pregnancy test from a local pharmacy. To her dismay, the test was positive. In order to confirm the pregnancy, she traveled alone to the nearby health center in her town to obtain a blood test. Again, the test was positive. She had never been pregnant before and she was terrified. In the midst of her fear, she shared the results with her rapist, her godfather.

His response: get an abortion. He did not want to lose his wife and children if they found out about the pregnancy.

Other than their illegal nature, Ana Maria knew nothing about abortions – where to get one, how it was done, what it felt like. She asked her neighbors to explain it to her. They said “it was worse than having a baby and [experiencing] childbirth.”

Though Ana Maria did not want to get the abortion, her godfather continued to pressure her to get the procedure saying, “Regardless, you must get the abortion… you are not the first woman to have ever had one.” Similar to the emotional violence before he raped her, he called and texted Ana Maria every day telling her to, “do it as fast as you can.” He forbade her from telling anyone about the pregnancy and Ana Maria didn’t feel like she had anyone to confide in about the situation. She worried about people judging her for getting pregnant outside of a committed relationship – even though she was raped. Ana Maria described this difficult time:

“When he started to pressure me [to get the abortion], I felt alone. I did not have enough trust in anyone to tell them [what had happened] because… if I had had enough trust in someone, I know that they would not have let me do it. If I had been given advice, they would have said, ‘No, do not do it,’ but I did not have anyone and I felt so depressed. What made it worse, I couldn’t sleep; I could not sleep [because I was] thinking of everything he had told me. At night, I would remember how it all started and I do not know what he did to find that money, but he gave me the money to get the abortion.”

Her godfather gave her 3000 Córdobas (approximately USD112 at the time) and put her on a public bus, alone. He had arranged for her to receive the abortion from an older woman that practiced “natural medicine” in a nearby city. When Ana Maria arrived at the woman’s home, she was instructed to remove her pants and underwear and lie on a bed. Ana Maria did not receive any medication before the woman inserted a “device like the one used for a Papanicolau… and then another device like an iron rod” into her vagina.

After describing these devices, Ana Maria made a jerking motion back and forth with her arm to imitate the movement the woman used to perform the abortion.

Once it was over, the woman gave Ana Maria an injection of an unknown substance and told her that she would pass a few blood clots over the next few days. That night, however, Ana Maria’s condition worsened; she became feverish, felt disoriented, and began to pass dark, fetid clots of blood. She described the pain she experienced throughout the ordeal:

“I felt so much pain when they took her out of me. I felt pain when the blood was leaving my body and when I had the fever. I felt a terrible pain that only I suffered. I am [a] different [person] now because of those pains.”

Ana Maria was too afraid to tell her family about the assault or the abortion because she was uncertain how they would react. She was even more terrified of the potential legal repercussions that she could face for violating the total ban on abortion. Within a few days of the abortion, though, Ana Maria’s brother heard rumors of his sister’s situation from neighbors “in the street” and confronted her about what had happened. At first, Ana Maria denied that she had had an abortion, but her brother continued to ask for the truth. Though she was nervous, Ana Maria eventually told her brother everything that had happened – from her godfather’s incessant verbal harassment, to the rape, to the unsafe abortion she was forced to get.

Afraid for his sister’s life, Ana Maria’s brother contacted a local nurse who discreetly provides postabortion care (PAC) to women experiencing complications from unsafe abortion and other obstetric emergencies. This nurse is locally known to be one of the few health care providers who provide PAC despite many other providers’ fear of prosecution under the total ban. The nurse recommended that Ana Maria come to the hospital immediately.

Ana Maria spent almost two weeks as an inpatient at the only hospital in the region. She had become septic as a result of what she described as a “perforated uterus,” a common complication from unsafe abortion. [ 28 ] Upon her initial examination, the nurse was afraid that her uterus could not be repaired because the infection was so severe. Fortunately, the medical team administered an ultrasound, removed infected blood clots, and completed uterine surgery to repair the damage from the unsafe abortion. At the request of the gynecologist taking care of her, Ana Maria received the one-month contraceptive hormonal injection before being discharged. At the time of the interview, Ana Maria had not received the next month’s injection because she “didn’t have any use for a man.”

As a result of this experience, Ana Maria reported feelings of depression, isolation, and recurring dreams about a little girl, which she described in this way:

“After I was discharged, I always dreamt of a little girl and that she was mine, standing in my doorway and when I awoke, I couldn’t find her. I looked for her in my bed but she wasn’t there. And this has tormented me because, it’s true: I am the girl that committed this error, but the little girl was not at fault. He pressured me so strongly to get the abortion, so I did.”

Ana Maria had the same recurring dream every night for more than two weeks and she continued to feel depressed weeks after leaving the hospital. One of the sources of her depression was the isolation she felt because there was no one with whom she could share this experience.

According to Ana Maria, she longs to have other people to talk to about her experience – particularly those who may have had similar experiences. She also expressed a desire to pursue a law degree so that she can have a career in local government.

Discussion and conclusions

Ana Maria’s case provides insight into the contextual factors effecting her ability to realize her sexual and reproductive health and rights in Nicaragua where restrictive legal policies and conservative cultural norms around sexuality abound. These contextual risk factors include social norms related to sexual health, laws targeting VAW, and the criminalization of abortion.

Social norms related to sexual health

The fundamental relationship between structural inequality and sexual and reproductive rights has been duly noted; gender inequality, in particular, must be addressed in order to fulfill sexual rights for women. [ 29 ] As in many cases in Nicaragua, the fact that Ana Maria’s first sexual experience was nonconsensual and was initiated by an older male and trusted family friend highlights the uneven power relations between men and women in Nicaraguan culture, which propagate high instances of VAW and sexual assault. In a patriarchal society where machismo and gender inequality run rampant, women’s sexuality is further constrained by the stigmatization of sexual health and a culture of violence that limits women’s autonomy. The compound stigma surrounding sexual health in general, and rape in particular, negatively impacted Ana Maria’s knowledge and ability to access mental health and SRH services, including emergency contraception and post-rape care, which may have assisted her immediately following her assault. Before her brother intervened, Ana Maria’s fear of judgment and legal repercussions also prevented her from seeking PAC, which was necessary to save her life.

Comprehensive sexual education is a primary way to challenge these social norms and widespread stigma surrounding sexuality and SRH services, such as contraception and PAC, at the population level. Such education might have mitigated Ana Maria’s experience of unintended pregnancy through the provision of advance knowledge of emergency contraception and medical options in the event of pregnancy. CEDAW has recognized this missed opportunity for public health intervention in Nicaragua, and recommends sexual education as a means of addressing stigma related to sexuality, decreasing unintended pregnancy, and increasing the acceptability and use of family planning services throughout the country. [ 21 ] Furthermore, the lack of adolescent-friendly sexual education and SRH services symbolizes a social reluctance to acknowledge the reality that young people have sex. [ 30 ] Such ignorance results in a lack of information on healthy relationships and human reproduction, as well as experiences of unintended pregnancy, early motherhood, and unsafe abortion. Exposure to this type of information may have improved Ana Maria’s ability to protect herself, mitigated the impact of Nicaragua’s pervasive misogyny on her decision making, and lessened the influence of her godfather’s coercion before her experiences of rape and unsafe abortion.

Individual and structural violence against women

Though we do not know explicit details of Ana Maria’s rape, the act of rape is inherently violent. The assault violated her right to enjoy sexual experiences free from coercion and violence. [ 3 ] To further constrain her sexual and reproductive rights, Ana Maria’s experience of rape resulted in an unintended pregnancy and an unsafe abortion that she was pressured into undergoing. Along with physical sequelae as a result of the procedure, she also expressed feelings of depression and isolation, which are common symptoms of post-traumatic stress disorder (PTSD). [ 31 ] These mental health consequences are forms of emotional violence that Ana Maria continued to experience long after the initial insult of physical violence. We can’t distinguish whether her mental health symptoms were a pre-existing condition or a result of the traumatic experience presented here. It is likely, however, that all parts of this experience impacted her mental and physical health. As reported elsewhere, perceived social criticism and a lack of social support are barriers to the fulfillment of sexual and reproductive health among young Nicaraguan women. [ 18 ] These contextual risk factors undoubtedly played a role in Ana Maria’s ability to navigate the circumstances surrounding her assault and its aftermath.

What legal recourse was feasibly available to Ana Maria for the crime of her sexual assault? To our knowledge, Ana Maria did not report the rape to authorities nor did her godfather ever face criminal charges for his actions. Yet Ana Maria’s own fear of prosecution for undergoing the unsafe abortion, as well as shame and fear of being stigmatized by others in her community, strongly influenced her decision not to report the rape -- even though Law 779 contains sanctions specific to those who commit rape.

In the event she had reported the crime, however, it is unclear if Law 779 would have provided justice. There are no data to suggest that Law 779 has led to an increase in the reporting or prosecution of rape at the national level. To the contrary, qualitative work in Nicaragua found a perceived increase in VAW following the passage of the law. [ 14 ] In Nicaragua, the inconsistent or ineffective enforcement of Law 779 is another factor worthy of consideration in cases like Ana Maria’s where individuals do not report such crimes. Documents like the UN Women Model Protocol have recently been released to improve the enforcement of laws like Law 779 in Latin American countries, presenting an opportunity for the effective operationalization of the law in Nicaragua. [ 32 ] If Law 779 is not adequately enforced, women like Ana Maria face the potential for re-victimization through the structural violence of impuity and continued exposure to VAW. To our knowledge, Ana Maria’s perpetrator faced no consequences for his perpetration of harassment, coercion and rape of Ana Maria. Moreover, in countries where abortion is criminalized, such as El Salvador, it is most often women who face criminal sanctions. [ 33 ] Indeed, it was Ana Maria herself who bore the physical and mental burden that resulted from her assault, unintended pregnancy, and unsafe abortion.

The criminalization of abortion

The criminalization of health services is a strategy that governments use to regulate people’s sexuality and sexual activity. [ 34 ] The criminalization of services such as abortion limits women’s ability to make autonomous decisions about their SRH. By definition, laws that restrict access to health services exclude people from receiving the information and services necessary to realize the highest level of SRH possible. [ 5 ] The criminalization of abortion puts the health and well-being of individuals and communities at risk. Beyond the individual level, complications from unsafe abortion often put unnecessary and immeasurable financial burdens on health systems that are already stretched [ 28 ].

Ana Maria did not have a choice when it came to her abortion; the man who raped her coerced her to undergo an unsafe and illegal procedure. The criminalization of abortion in Nicaragua put Ana Maria’s health at risk in two ways: first, it prevented her from obtaining a safe abortion and second, it limited her access to comprehensive sexual health information that could have helped her address her unintended pregnancy, through emergency contraception. After the unsafe abortion procedure, her access to PAC was likely constrained by her own fear of the possible legal repercussions of undergoing an abortion, and was compounded by her inability to trust that a health care provider would maintain patient confidentiality and provide adequate PAC.

In Nicaragua, the total ban on abortion directly contradicts strategic objectives outlined in the Beijing Declaration, which guarantees women’s rights to comprehensive SRH care, including family planning and PAC services. Though providing PAC is not considered illegal under the total ban, many Nicaraguan health care providers refuse to treat women who have had unsafe abortions, which results in a ‘chilling effect’; providers do not want to be accused of being complicit in providing abortions so they refuse to provide PAC services. The ‘chilling effect’ put Ana Maria at risk of morbidity or mortality as a result of the complications that resulted from her unsafe abortion.

Equally troubling is the use of criminal law against individuals like Ana Maria as well as health care professionals that provide PAC. By requiring health care providers to report to the police women who have had abortions, the total ban violates the privacy inherent in the patient-provider relationship. Health care providers are faced with a dual loyalty to both the State’s laws and the confidentiality of their patients, which makes it difficult for providers to fulfill their professional obligations. It also makes health care professionals complicit in a discriminatory practice, one where women face legal sanctions in ways that men do not. The criminalization of abortion in Nicaragua therefore resulted in the fear, stigma, discrimination, and negative health outcomes observed in Ana Maria’s case.

The contextual risk factors that contributed to Ana Maria’s experience of rape, unintended pregnancy, and unsafe abortion are as follows: sexual assault, impunity for violence, gender inequality, restrictive social norms around SRH, stigma resulting from unintended pregnancy and abortion, harmful health impacts from an unsafe abortion, and fear of prosecution due to the total ban. Her first sexual experience was forced and nonconsensual and preceded by months of harassment. Social norms made taboo any discussion of the harassment and sexual violence she experienced at the hands of her godfather; without social support, she was coerced into undergoing an unsafe abortion that resulted in serious mental and physical health sequelae. The illegal nature of abortion in Nicaragua placed Ana Maria at risk for social stigma as well as criminal prosecution. Her subsequent underutilization of family planning services at the time of the interview also placed Ana Maria at risk for an unintended pregnancy in the future; other long-term physical and mental health effects of her experience remain unknown.

The realization of one’s sexual and reproductive rights guarantees autonomous decision-making over one’s fertility and sexual experiences. However, Ana Maria’s story demonstrates that an individual’s SRH decisions are not made in isolation, free from the influence of social norms and national laws. Far too many women experience their sexuality in the context of individual and structural violence, such as VAW and gender inequality. This case highlights the contextual risk factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion; we must continue to critically investigate these factors to ensure that experiences like Ana Maria’s do not become further normalized in Nicaragua. Due to restrictive social norms around SRH, Ana Maria grew up experiencing stigma and taboo associated with sex, sexuality, contraceptive use and abortion. She also lacked access to information regarding SRH, healthy relationships, and how to respond to VAW before she was assaulted. After her assault, she did not have access to post-rape care, emergency contraception, safe abortion services, or mental health services to help her process this trauma. Shame and fear of stigma also prevented Ana Maria from reaching out for social support from family, friends, or the health or legal system. From the legal perspective, inadequate enforcement of VAW laws and the criminalization of abortion further exacerbated the trauma Ana Maria experienced.

It would require active engagement from the Nicaraguan government to address the contextual risk factors identified herein to protect their citizens’ right to health and prevent future experiences like Ana Maria’s. These efforts are particularly relevant given recent political unrest throughout Nicaragua including anti-government protests demanding the president’s resignation. [ 35 ] Nicaraguans’ right to health is at risk not only due to the widespread violence, but also because health care workers are being dismissed and persecuted nationwide. [ 36 ] Sexual and reproductive health researchers, advocates, and the public will continue to monitor Nicaragua’s response to the immediate demands and needs of its citizens -- including the demand that Nicaraguan women like Ana Maria are able to fully exercise their sexual and reproductive rights in times of both conflict and peace.

Availability of data and materials

Deidentified data are available upon reasonable request.

Abbreviations

Committee on Civil and Political Rights

Committee on the Elimination of all forms of Discrimination Against Women

In-Depth Interviews

Postabortion Care

Post-Traumatic Stress Disorder

Socioeconomic Status

Sexual and Reproductive Health

United Nations

Violence Against Women

World Health Organization

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Acknowledgements

The authors thank the research team and in-country collaborators from Proyecto Paz y Amistad, as well as the Emory University Global Field Experience (GFE) Fund and the Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund for financially supporting this project. We are also grateful to Ellen Chiang for her editorial support.

This study was funded with support from the Emory University Global Field Experience (GFE) Fund and the Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund. The funders did not play any direct role in the design of the study; the collection, analysis, and interpretation of data; or the writing of the manuscript.

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All authors contributed extensively to the work presented in this manuscript. SML, DPE, and RWR jointly designed the study. SML performed data collection and data analysis. SML and DPE wrote the manuscript with significant input from RWR. DPE and RWR also provided support and supervision throughout the study. All authors read and approved the final manuscript.

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Emory University’s Institutional Review Board found the study exempt from review because it did not meet the definition of “research” with human subjects as set forth in Emory policies and procedures and federal rules. The authors partnered with Proyecto Paz y Amistad, a local organization to design and implement this study. Proyecto Paz y Amistad deferred to the Emory University IRB’s determination. Nicaragua is notably absent from the US Department of Health and Human Services, International Compilation of Human Research Standards ( https://www.hhs.gov/ohrp/sites/default/files/2018-International-Compilation-of-Human-Research-Standards.pdf ). To our knowledge, there were no existing national level human subjects requirements or exemptions at the time of data collection.

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Luffy, S.M., Evans, D.P. & Rochat, R.W. “Regardless, you are not the first woman”: an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua. BMC Women's Health 19 , 76 (2019). https://doi.org/10.1186/s12905-019-0771-9

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• 16 November 2021

Yes, science can weigh in on abortion law

• Diana Greene Foster 0

Diana Greene Foster is director of research at Advancing New Standards in Reproductive Health at the University of California, San Francisco, and author of the book The Turnaway Study (2020).

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The world is moving towards greater reproductive rights for women. More than 50 countries have liberalized their abortion laws in the past 25 years, informed by scientific research. Studies find that unsafe abortion is responsible for one in eight maternal deaths globally ( E. Ahman and I. H. Shah Int. J. Gynaecol. Obstet . 115 , 121–126; 2011 ), concentrated in low-income countries where abortion is illegal. Preventing unsafe abortion is a priority — 193 countries signed up to the United Nations Sustainable Development Goals, which call for reductions in maternal mortality.

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Public Health in the Field: The Public Health Case for Abortion Rights

Annalies Winny

Lindsay Smith Rogers

This article is adapted from a special episode of the Public Health On Call Podcast called Public Health in the Field. You can hear the full episode here .

Please note: Throughout this article, the gendered terms “woman” and “women” are used as that’s how the CDC and other sources record related data. 

More coverage:

• Overturning Roe v. Wade and Public Health
• What We Know—and Don't Yet Know—About The Leaked Supreme Court Draft Opinion That Could Overturn Roe v. Wade

A single case before the Supreme Court will likely decide the future of Roe v. Wade.

In 2018, the Mississippi legislature passed and the governor signed House Bill 1510, known as the  Gestational Age Act , which bans abortions after 15 weeks. There are exceptions if the life of the fetus or parent is at risk—but not in cases of rape or incest. The law violated Roe v. Wade, a Supreme Court decision that protects the right to abortion prior to “viability” of the fetus, which is at around 24 weeks. The bill was quickly blocked by lower federal courts but now the law’s fate is up to the Supreme Court.

The outcome of this case— Dobbs v. Jackson Women’s Health Organization —has implications for abortion rights far beyond Mississippi: A decision that previability bans are not unconstitutional could upend longstanding protections established by Roe v. Wade, the 1973 landmark case that legalized abortion nationwide. 

The conversation about abortion rights in the U.S. is a noisy one involving politics, precedents, and personal beliefs. What often gets short shrift, however, is the public health reality that restricting access to abortion results in erosion of the health of women, especially low-income and women of color. This is why abortion is so much more than a legal battle. 

The Public Health Case for Abortion Rights

Many women who were denied wanted abortions had higher levels of household poverty, debt, evictions, and other economic hardships and instabilities, according to Joanne Rosen , JD , associate director of the  Johns Hopkins Center for Law and the Public’s Health .

The findings come from a 10-year study,  The Turnaway Study , which followed nearly 1,000 women who either had or were denied abortions and tracked their mental and physical health and financial impacts. 

“The study also found that women who were seeking but unable to obtain abortions endured higher levels of physical violence from the men who had fathered these children,” Rosen says. “And people who were turned away when seeking abortions endured more health problems than women who were able to obtain [them], as well as more serious health problems.

“That gives you a sense of the ways in which being unable to obtain abortions had really long lasting impacts on these peoples’ lives.”

A 2020 study in the  American Journal of Preventive Medicine found that women living in states with less restrictive reproductive health policies were less likely to give birth to low-weight babies. Other research  published in The Lancet found that restrictive abortion laws actually mean a higher rate of abortion-related maternal deaths.

Restrictive abortion laws affect more than just the health of individuals and families—they affect the economy, too. Research from The Lancet found that “ensuring women’s access to safe abortion services does lower medical costs for health systems.”  

The  Institute for Women’s Policy Research has a host of data around how reproductive health restrictions impact women’s earning potential, including an interactive map tool, Total Economic Losses Due to State-level Abortion Restrictions. In Mississippi , for example, the data indicate that an absence of abortion restrictions would translate to a 1.8% increase of Black women in the labor force, over 2% for Hispanic women, and a leap of more than 2.6% for women who identify as Asian-Pacific Islander. This same tool calculates that removing abortion restrictions would translate to an estimated $13.4 million in increased earnings at the state level for Black women alone. 

Abortion restrictions disproportionately affect people of color and those with low-incomes. According to  data from the CDC , Black women are five times more likely to have an abortion than white women, and Latinx women are two times as likely as whites. Seventy-five percent of people who have abortions are low-income or poor. 

Mississippi, Texas, and The Supreme Court   

On December 1, the Supreme Court will hear Dobbs v. Jackson Women’s Health Organization and Joanne Rosen thinks it’s unlikely the Court would agree to hear the case if they were just going to affirm the status quo. 

The case isn’t the only one on the docket, however. Texas’ Senate Bill 8, which bans abortion after six weeks of pregnancy, made headlines earlier this month and may impact SCOTUS’ ultimate decision on the Mississippi case. The high-profile law came before the Supreme Court in November 2021 and Rosen said the important thing to note is that the Court didn’t actually address whether the six-week ban is constitutional. Rather, they examined the unusual enforcement scheme of the law—where, when, and by whom the Texas law could be challenged.

Rosen says that the justices may compare the Texas law with the Mississippi law and, when considering a six-week abortion ban, a 15-week ban may seem less extreme. In this way, the Texas case could give the Court some cover to uphold Mississippi’s 15-week ban.

It’s likely to be months before an opinion is released; Rosen says the Court typically releases its decisions on high-stakes or controversial cases in June. And high stakes this is: for the future of abortion, for reproductive health rights, and for public health. 

Annalies Winny is an associate editor for  Global Health NOW . 

Alissa Zhu is a journalist and current  MSPH student at the Bloomberg School.

Lindsay Smith Rogers, MA, is the producer of the  Public Health On Call podcast and the associate director of content strategy for the Johns Hopkins Bloomberg School of Public Health.

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• Published: 06 April 2021

Strengthening healthcare providers’ capacity for safe abortion and post-abortion care services in humanitarian settings: lessons learned from the clinical outreach refresher training model (S-CORT) in Uganda, Nigeria, and the Democratic Republic of Congo

• Nguyen Toan Tran   ORCID: orcid.org/0000-0001-7134-7878 1 , 2 , 3 ,
• Alison Greer 3 ,
• Talemoh Dah 4 ,
• Bibiche Malilo 5 ,
• Bergson Kakule 6 ,
• Thérèse Faila Morisho 6 ,
• Douglass Kambale Asifiwe 6 ,
• Happiness Musa 7 ,
• Japheth Simon 7 ,
• Janet Meyers 8 ,
• Elizabeth Noznesky 9 ,
• Sarah Neusy 10 ,
• Burim Vranovci 2 &
• Bill Powell 11  

Conflict and Health volume  15 , Article number:  20 ( 2021 ) Cite this article

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Fragile and crisis-affected countries account for most maternal deaths worldwide, with unsafe abortion being one of its leading causes. This case study aims to describe the Clinical Outreach Refresher Training strategy for sexual and reproductive health (S-CORT) designed to update health providers’ competencies on uterine evacuation using both medications and manual vacuum aspiration. The paper also explores stakeholders’ experiences, recommendations for improvement, and lessons learned.

Using mixed methods, we evaluated three training workshops that piloted the uterine evacuation module in 2019 in humanitarian contexts of Uganda, Nigeria, and the Democratic Republic of Congo.

Results from the workshops converged to suggest that the module contributed to increasing participants’ theoretical knowledge and possibly technical and counseling skills. Equally noteworthy were their confidence building and positive attitudinal changes promoting a rights-based, fearless, non-judgmental, and non-discriminatory approach toward clients. Participants valued the hands-on, humanistic, and competency-based training methodology, although most regretted the short training duration and lack of practice on real clients. Recommendations to improve the capacity development continuum of uterine evacuation included recruiting the appropriate health cadres for the training; sharing printed pre-reading materials to all participants; sustaining the availability of medication and supplies to offer services to clients after the training; and helping staff through supportive supervision visits to accelerate skills transfer from training to clinic settings.

Conclusions

When the lack of skilled human resources is a barrier to lifesaving uterine evacuation services in humanitarian settings, the S-CORT strategy could offer a rapid hands-on refresher training opportunity for service providers needing an update in knowledge and skills. Such a capacity-building approach could be useful in humanitarian and fragile settings as well as in development settings with limited resources as part of an overall effort to strengthen other building blocks of the health system.

Approximately two-thirds of maternal deaths worldwide occur in countries affected by fragility and crises [ 1 ]. Unsafe abortion is one of the leading causes of maternal mortality and morbidity, with 5–13% of attributed maternal deaths worldwide [ 2 ] and South Asia and sub-Saharan Africa accounting for an overwhelming majority of these deaths [ 3 ]. Therefore, emergency care for women with abortion complications (post-abortion care) and safe termination of pregnancy (safe abortion care) are lifesaving [ 4 ].

As such, the Minimal Initial Service Package (MISP) for Sexual and Reproductive Health (SRH) in humanitarian settings—an international standard in humanitarian response to be delivered from the onset of a crisis [ 5 ]—has a four-prong integration of these services into its objectives [ 6 ]. First, under the MISP objective on sexual violence, pregnancy testing, pregnancy options information, and safe abortion care/referral for safe abortion care, to the full extent of the law are components of the clinical care for survivors [ 6 ]. Second, post-abortion care is a signal function of emergency obstetric care and falls under the MISP objective to prevent excess maternal morbidity and mortality [ 6 ]. Third, ensuring that safe abortion care is available in health centers and hospitals to the full extent of the law is a standalone priority of the MISP [ 6 ]. Lastly, voluntary contraception, which is reflected in the MISP objective on preventing unintended pregnancy, is a key component of post-abortion and safe abortion care services [ 6 ].

Nonetheless, abortion-related knowledge (including of national laws), technical skills, and services are notably lacking in most crisis settings as illustrated by various evaluations and reviews, which found inconsistent to non-existent service delivery of contraception (in particular long-acting methods) and safe abortion care in crisis settings [ 7 , 8 ] and called for special attention on this underserved issue [ 9 ]. Likewise, these services were under-represented in humanitarian appeals and funding allocations [ 10 ], and the topic received little attention in terms of health intervention research in humanitarian crises [ 11 ].

Safe abortion services may be perceived as too complicated to implement [ 12 ] or unrealistic to offer openly in humanitarian contexts [ 13 ]. In terms of required clinical competency, mid-level providers can safely perform uterine evacuation using manual vacuum aspiration (MVA), medications, or both, after appropriate training [ 14 ]. To help ensure there is clinical staff available with the knowledge and skills to provide these services in crisis-affected and fragile settings, Ipas and the Training Partnership Initiative of the Inter-Agency Working Group for SRH in Crisis-Settings collaborated to develop a refresher training course on uterine evacuation covering both MVA and medication approaches. The course adopted an established capacity-building strategy known as the S-CORT (SRH Clinical Outreach Refresher Training) [ 15 ]. The model is not meant to build the capacity of people who have not been previously trained on MVA. Instead, it aims to reach out to frontline health providers working in humanitarian contexts, such as nurses and midwives, and refresh their knowledge and skills on lifesaving SRH skills, which they previously learned but may not have kept up to date. Such training courses last two to 3 days depending on the topic and usually do not include a clinical practicum. The uterine evacuation module was designed to be used either as a stand-alone one-day training focusing on the medications approach or as a two-day training combining both medications and MVA. In contrast to other S-CORT modules, the training on medication-based uterine evacuation is appropriate for either new learners or as a refresher course because it is a knowledge-based clinical service that does not require further hands-on clinical skills. This paper is a case study describing the design and contents of the S-CORT on uterine evacuation, lessons learned from its implementation, and stakeholders’ experience in humanitarian contexts in Uganda, Nigeria, and the Democratic Republic of Congo (DRC), as well as recommendations for improvement.

In 2019, Uganda hosted close to 1.4 million refugees, with a majority from South Sudan, followed by DRC and Burundi [ 16 ]. Although the Ugandan Constitution declares that no person has the right to terminate the life of an unborn child except as may be authorized by law (Penal Code of 1950, Section 141) , its 2012 SRH policy clarified the exceptions to the rules allowing induced abortion under specific circumstances, including rape and incest as well as severe maternal and fetal conditions [ 17 ]. However, these exceptions have not been made explicit and consistent within the law and across policies, resulting in a lack of knowledge, understanding, and coherent application of the law, and concern among clinical providers about being penalized for providing abortion services, which impacts their availability [ 18 ]. Approximately 375 women die from pregnancy-related causes out of every 100,000 live births nationwide [ 1 ]. Unsafe abortion is seen as a major contributor to maternal mortality and there is a high demand for but insufficient access to safe abortion services. A study estimated that, in 2013, 52% of pregnancies were unplanned, 314,304 induced abortions were performed, and 128,682 women were treated for abortion-related complications in health facilities [ 19 ].

The protracted armed conflict in Northeast Nigeria resulted in around 1.8 million internally displaced people in 2019 [ 20 ]. The country’s restrictive laws, which differ in Northern and Southern Nigeria, permit induced abortion only to save a woman’s life [ 21 ]. Due to their criminalization, the majority of abortions occur in unsafe conditions, as illustrated by the estimated 1.25 million women nationwide who had an induced abortion in 2012 with the highest number in Northeast Nigeria [ 22 ]. Among the 1.25 million women, 212,000 received treatment for complications of unsafe abortions, while 285,000 experienced serious health consequences but did not receive treatment. The national maternal mortality ratio in 2017 was 917 per 100,000 live births [ 1 ].

In 2019, 12.8 million people needed humanitarian assistance in DRC, with the eastern region particularly affected by decades of armed conflict, political unrest, and fragility compounded in recent years by Ebola Virus Disease outbreaks [ 23 ]. Before March 2018, induced abortion was not legal under any circumstance in the DRC. However, an article in the code of medical ethics allowed doctors to perform the service to save a woman’s life [ 24 ]. In 2018, the DRC endorsed the African Charter on Human and People’s Rights on the Rights of Women in Africa (Maputo Protocol), which allowed women to legally access abortion under a broader range of conditions—including in cases of sexual assault, rape, or incest [ 25 ]. There is no published report on abortion incidence except for Kinshasa, where an estimated 37,865 women obtained treatment for induced abortion complications in health facilities in 2016 [ 26 ]. The maternal mortality ratio reported in 2017 was 473 per 100,000 live births [ 1 ].

Despite differences among the three countries regarding their abortion laws, all allowed access to postabortion care (emergency care for women with abortion complications), reflecting its legality globally [ 27 ]—even countries with highly restrictive abortion laws recognize postabortion care as a critical component of essential emergency obstetric care.

Intervention

The S-CORT approach is designed for individual or group-based training with a focus on participatory learning and skills practice. The training package comprises a facilitator’s guide (see https://iawg.net/resources/uterine-evacuation-in-crisis-settings-using-mva-refresher-training ) and slide sets with seven units for the trainer and handouts, checklists, and job aids for participants. The agenda is modular to accommodate a stand-alone medication or MVA training or a combination of both. The module on uterine evacuation using medication covers post-abortion care and safe abortion care (with combined mifepristone and misoprostol or misoprostol-only regimens). Training methodologies include slide-supported interactive presentations, group discussions, and questions and answers, case studies, small group work, role-plays, videos, and demonstration and hands-on skills practice with anatomical models along with checklists to guide practice. The training module contents drew from the latest available resource materials, including guidance from the World Health Organization (WHO) and Ipas Woman-Centered, Comprehensive Abortion Care: Trainer’s Manual, and were adapted for humanitarian contexts [ 4 , 28 ].

Selection of implementing partners

In 2019, Ipas and the Training Partnership Initiative of the Inter-Agency Working Group for SRH in Crisis-Settings partnered with three implementing organizations solicited through an open application process to pilot the module. Criteria for implementing organizations included having safe abortion care or post-abortion care, or both, within the organization’s workplan; prior experience organizing trainings in crisis-affected settings; commitment to supporting capacity development efforts for national and international SRH providers; and capacity to undertake an evaluation of the module and training workshop.

Pilots were held in Yumbe, Uganda, in April 2019 with Médecins du Monde France and in Maiduguri, Nigeria, in July 2019 with CARE Nigeria. Both trainings were conducted in English. For the third pilot held in Goma, DRC, in August 2019, the training materials were edited for compliance with the U.S. policy on Protecting Life in Global Health Assistance (PLGHA) (see Fig. 1 ). The materials were then translated into French, which was the language used during the training. This pilot was a collaboration with CARE DRC and Save the Children DRC. In each setting, an Ipas trainer from the national or international office was the lead or co-facilitator. These training courses were attended by doctors, nurses, midwives, and other mid-level providers. While many reported some prior exposure to or experience with MVA, only a few did so for uterine evacuation using medication.

Adapting abortion and post-abortion care programs to the U.S. policy on Protecting Life in Global Health Assistance [ 29 ]

Partners were provided the option to pilot the uterine evacuation module with medications alone or in combination with MVA. All selected the combined training. A values clarification and attitude transformation (VCAT) session is strongly recommended in advance of the uterine evacuation with medications and MVA trainings [ 30 ]. As such, a one-day VCAT workshop preceded the clinical training in Nigeria. In DRC, a VCAT exercise was integrated into the agenda of the first day. In Uganda, all participants had previously participated in a VCAT workshop.

Evaluation objectives

The evaluation had two primary objectives: first, to evaluate the training materials themselves, including the clinical outreach training model, which would help inform the finalization of the design and contents of the training package, and, second, to evaluate the implementation of the training, which will strengthen the guidance around organizing such trainings.

The evaluation of the module adopted a mixed-method approach, which included a self-filled pre-test and post-test questionnaire, a competency checklist, a self-filled end-of-training evaluation, and qualitative interviews with participants.

Pre-test and post-test

The questionnaire comprised 24 multiple-choice questions in English or French and was administered at the beginning and end of the training workshop. The questions aimed at assessing the level of knowledge related to the continuum of care for uterine evacuation from counseling to contraception. They stemmed from a pool of questions that Ipas had pilot-tested and utilized in numerous training workshops worldwide. Mean scores were computed.

Competency checklist

Clinical competency was assessed at the beginning and at the end of the workshop using checklists comprising 63 systematic steps for medication uterine evacuation and 78 for manual vacuum aspiration. Anatomical models were used for MVA and role-plays for medication uterine evacuation. Due to their limited number, facilitators could not observe each participant and complete the checklist accordingly. This was done by a fellow participant under the supervision of a facilitation team member. Mean scores were computed. However, data from the competency checklists were incomplete and therefore unreliable for analysis.

Qualitative data

At the end of the workshop, an independent evaluation staff from the main implementing partner conducted focus group discussions with participants. The evaluation teams used convenience sampling for participant selection by inviting trainees to participate and by ensuring equitable representation by gender and professional profiles. The focus group discussions were audiotaped after obtaining agreement from participants. Research assistants transcribed the audio recordings into English or French with accuracy checks done by comparing transcripts with audio files. Focus group discussions gathered male and female trainees, and, therefore, the transcriptions did not report the distinction between genders. Written comments from end-of-workshop evaluations by participants and feedback from trainers provided additional sources of qualitative data. Thematic analysis was performed by qualitative analysts fluent in both French and English using QSR NVivo 12 software, a qualitative research management tool. A basic codebook, which describes all the codes used for analysis, was pre-established based on the discussion guide and used to code data. The codebook was enriched with new codes as they emerged during the coding process.

Ethics and informed consent

The pre- and post-workshop surveys and qualitative tools were part of planned program monitoring, which was not designed to develop and contribute to generalizable knowledge and, therefore, did not constitute research and require ethical approval [ 31 ]— this was confirmed by our submission to the Western Institutional Review Board (No. 2633824–44,635,729). The evaluation was deemed to pose no risk, and there was no requirement for workshop participants to complete the evaluation as a condition of workshop attendance and no incentive in participating in the evaluation. Therefore, there was no need for informed consent. Evaluators informed participants that their participation in the evaluation was voluntary, all their feedback would be anonymized, and its management and analysis handled confidentially. No patient participated in the evaluation.

Between 15 April and 31 August 2019, implementing partners ran a three-day or four-day pilot training workshop in each of the three participating countries (Table  1 , Part 1). The nature of all three contexts was humanitarian or fragile. The number of participants ranged from 21 to 30 per workshop with a total of 72 people (35 women and 37 men). They were nurses, midwives, physicians, medical coordinators, and programmatic staff affiliated with the partnering organization. In Nigeria and the DRC, members of the Ministry of Health participated in the training. In Nigeria, there were ten community health extension workers and one radiologist—this was contrary to the recommended criteria for participants and part of the lessons learnt (see Discussion).

The core curriculum comprised a day on manual vacuum aspiration and another one addressing medication-based uterine evacuation. On the basis of participants’ needs and available resources, facilitators added a first day dedicated to abortion values clarification and attitude transformation (Nigeria, DRC) and all three workshops included a day of validation of clinical competencies with real clients or through role-plays using humanistic models if no planned clients showed up. In all three countries, facilitators included a discussion on ways to integrate uterine evacuation into health facilities in humanitarian settings, which is part of the monitoring and evaluation chapter of the module.

In all three countries, results for the knowledge pre-test and post-test were available. As mentioned under Methods, data from the competency checklists were incomplete and therefore unreliable for analysis (Table  1 , Part 2). In DRC, an evaluation officer conducted three focus group discussions with a total of 5 women and 14 men. In Uganda, due to limited resources, one of the facilitators had to conduct just one focus group discussion with 3 women and 3 men and another facilitator provided written feedback on the use of the facilitator’s guide. In Nigeria, there were two focus group discussions. However, the recording and audio files, which contained the details about the number of participants and their gender, were corrupt and therefore not usable.

The average scores of participants rose significantly in all three countries but from different baselines and with different percentage point increase. In the DRC, the score increased from 56 to 76%; in Uganda, from 84 to 89% with the best improvement at + 25 percentage point; and in Nigeria, from 45 to 52% with the best improvement at 25 percentage point but a third of participants scored worse after than before. A participant in Uganda reported that the pre-test should be “less bulky, comprehensive, and cumbersome,” an impression echoed by participants from the other settings.

Qualitative results

Confidence, skills building, and relevance.

Participants from all three countries reported that the workshop enhanced their competencies, strengthened their confidence by overcoming fear to deliver uterine evacuation information and services, and eventually transformed their attitudes in relation to uterine evacuation.

Before, I even feared to talk about it because I could not even defend my thoughts. I really feared when somebody came to me and talked about abortion: tell me more about it, what is the service? I really did fear because I lacked the evidence, and I didn’t know what I was doing…I used to fear the complications. But I have also learned about how to manage complications and even how they can come about during the process. I know how to help with some of the complications that may come about, how it can also be avoided during the process. – Participant from Uganda.

When asked about what they would do differently as a consequence of the workshop, participants listed improving counseling, respecting all clients, and specific clinical procedures, including the administration of paracervical blocks or medication for pain control, as illustrated hereafter:

What I would do differently? A paracervical block before doing manual vacuum aspiration, pain management using ibuprofen, and know how to administer mife [mifepristone] in combination with miso [misoprostol] or give miso alone. – Participant from the DRC I will change my attitude. I will do follow up. I will do good counseling. I will have self-confidence, respect for all clients and provide quality care to all clients irrespective of age, religion, and marital status. – Participant from Nigeria

The previous quote came from the Nigeria workshop and suggests that the S-CORT curriculum could influence attitudinal changes related to the quality of care and non-discrimination even without a dedicated day on values clarification and attitude transformation. In addition, the need for non-discrimination was repeatedly underscored as well as freedom from shame, as exemplified hereafter:

This training has helped us not to discriminate anyone who has come for the service. So, you cannot discriminate this one who is young or this one who is old so you cannot do the procedure. It has helped us to do abortions to any client who really wants the service…I feared talking about abortion but now I’m okay because sometimes I see people dying, but I think helping these people about abortion is better than leaving them dying. And right now, I have come to really believe that with the knowledge I got, with the medical method and the evacuation, I can really help a lot of people in crisis and also, I will not feel so ashamed to talk with them, to counsel them so that I will not lose them. – Participant from Uganda

Participants reported the need to have a more concrete discussion—and examples—on how to improve the integration of their uterine evacuation skills into their healthcare services, as most providers found the training workshops relevant to their job:

This knowledge is very relevant to my profession being a comprehensive nurse. I have to know everything. Basic things in the medical profession so that I am able to handle any case. I cannot say this is a maternity case or this is a gyne[cological] case that has to be handled by midwives or doctors or something of that kind. So, I feel that this knowledge is very relevant to me so that it will help me to manage any case which presents to me. – Participant from Uganda

Counseling, human rights, and the law

Participants seemed adamant about the effect of the training on the way they would do counseling, reporting that their counseling would be underpinned by human rights principles, such as client autonomy and choice. In addition, the workshop appeared to have helped clarify the country’s legal framework for service providers, paving the way for fearless counseling and service provision.

I will do this service better since the grey areas I had were lifted with this training, since safe medical abortion is already allowed by the law of the country since it is a need felt in the population despite the ignorance of some . – Participant from the DRC

I have not been going through the counseling. But now, I realized much about counseling. And I have also realized that uterine evacuation goes hand in hand with counseling and then family planning. This one I did not know much about it… It is very important that you make her aware of the different types of family planning and the way we will do this uterine evacuation, being medical, being manual vacuum aspiration. So, that has really helped so much [to understand] that the woman, herself, will be able to decide what she wants, which choice she wants…This training really has helped change our attitudes because some of us used to think it should only be done to people who have been raped: they just sympathize with them, and induced abortion should not be done to others… – Participant from Uganda

Training methodology

Participants highly appreciated the balance between theory and practice through role-plays and skill rehearsal. The humanistic anatomical models were critical for skills demonstration by facilitators and for hands-on practice by participants.

The practice on the anatomic models and the exercises helped me assimilate the contents. However, we did not practice on [real] clinical cases, and the course was taught in a hurry. – Participant from the DRC

Many participants agreed with the perceived short duration of the workshop and the lack of clinical practice reported in the previous quote. Participants suggested adding one to two more days to their workshop, including the opportunity to practice with real patients in clinical settings. In all three countries, there were no patients available for the day planned for practice at the clinic. In this regard, trainees suggested the following actions for the organization of future workshops:

Prior to the training, we can liaise with facilities around to pool of patients possible for clinical practicum. Each case will offer an opportunity for further discussions. A day or two will need to be added for this purpose. A visit to one or two camps will help facilitators describe in clearer terms how services should be organized. – Participant from Nigeria

Participants generally appreciated the quality of the training materials but also reported a few gaps. As reflected earlier on the data incompleteness of the competency checklists, participants reported the need for clear instructions on how to use these checklists to practice skills and validate competencies. In addition, due to local delays in organizing the workshop, several participants in the DRC regretted not receiving hand-out documents.

No distribution of teaching aid before, during, or after the training. We will not know how to review the contents after the workshop . – Participant from the DRC

The materials are easy for the participants to understand. However, there is a need to improve on the instructions for the practical simulation and how co-participants can score themselves. – Participant from Nigeria

Participants shared other recommendations on how to improve their training experience. Figure 2 summarizes the key recommendations under four categories: curriculum revision, pre-workshop preparation, during the workshop, and after the workshop.

Summary of recommendations to improve the capacity development continuum

The newly developed S-CORT curriculum on uterine evacuation integrating manual vacuum aspiration and medication techniques was implemented in fragile or humanitarian contexts in Uganda, Nigeria, and the DRC. Results from the three workshops converged to suggest that the module contributed to increasing participants’ theoretical knowledge and possibly their technical and counseling skills. Equally noteworthy were their confidence building and positive attitudinal changes promoting a rights-based, fearless, non-judgmental, and non-discriminatory approach toward clients. Participants valued the hands-on, humanistic, and competency-based training methodology, although most regretted the short training duration and lack of practice on real clients.

We can draw several lessons to improve this S-CORT curriculum and the overall model as well as inform the design and implementation of new training curricula aimed at refreshing the knowledge and skills of service providers working in humanitarian settings.

First, this triple evaluation aligns with previous research on the S-CORT model, which suggests that the approach is respectful of human rights and quality of care principles in addition to being potentially effective in enhancing the knowledge and skills of existing trained service providers, strengthening their capacity, and changing their attitudes [ 15 ].

Combining medication uterine evacuation with manual vacuum aspiration within the same curriculum appeared feasible and indeed complementary as misoprostol and mifepristone are increasingly available in countries affected by fragility or crises [ 32 , 33 ]. Additionally, universal access to such medications, which are part of the WHO Model List of Essential Medicines [ 34 ], adhere to contemporary standards on sexual and reproductive health and rights [ 35 ].

Second, it is important to remember the S-CORT capacity development strategy: a rapid on-the-ground training during the acute or post-acute phase of a crisis to refresh the knowledge and skills of service providers on a specific lifesaving intervention, which they learned in the past. However, all three workshops, although implemented in fragile or humanitarian contexts, did not occur in acute crisis settings, and many of the participants did not have former training on uterine evacuation. Therefore, humanitarian coordinators should be considerate of the operational context, available resources, and profiles and needs of participants when planning for an extension beyond the two-day core training. For instance, adding an extra day for values clarification and attitude transformation is a best practice in uterine evacuation programming and should be a prerequisite if not done previously. However, if resources for an extra training day are constrained, the S-CORT curriculum already covers the topic to some extent in a condensed session. For those without prior exposure to uterine evacuation, and particularly hands-on MVA skills, a more comprehensive workshop over five or more days with ample opportunities for clinical practice would better meet their training needs. For the training to be both effective and efficient, participants should be screened in advance and training materials adapted to ensure the course is the most appropriate to meet their learning needs, background, and professional objectives [ 36 ].

Third, evaluating programs in unstable and resource-limited settings raises the question of balancing feasibility with validity [ 37 ]. The evaluation of our pilots had the merit of adopting a multi-pronged approach to shed light on changes in knowledge (pre-test and post-test), participants’ and trainers’ experience and perspectives (qualitative methods), and the strengthening of competencies (competency checklists). Our experience speaks against using competency checklists as a training program evaluation tool but illustrates the usefulness and feasibility of a mixed-method approach using qualitative research in addition to pre-tests and post-tests. These interviews provided nuances to the results of the written tests by exploring important skill retention factors, such as attitudinal changes or confidence [ 38 ]. Competency-based training requires a checklist to allow an observer (ideally a co-trainer, and, if not feasible, a co-trainee) to systematically record the status and progress for each step of the clinical competency to be acquired by a trainee. Such checklists are part of the S-CORT competency-building approaches and were used in all three pilots. We initially planned to capitalize on the availability of these checklists and integrate them into the mixed-method documentation of the pilots. There were 63 steps for medication uterine evacuation and 78 for manual vacuum aspiration. Collecting and cleaning this vast amount of data for each participant was a daunting task, which we underestimated. The checklist forms collected from all three workshops showed that they were used but with considerable incompleteness and inconsistencies, which did not allow us to exploit the data. Therefore, competency-based checklists should be used as a support to build trainees’ competencies rather than a workshop reporting tool. In this respect, it is critical for facilitators to clearly explain how to use the checklist and verify that trainees do so correctly and systematically to evaluate one another reliably. Such a checklist has the added value of serving as an ongoing training job aid for providers to rehearse and boost their clinical skills periodically after the training [ 39 ].

Regarding knowledge testing, the increase of the average post-test score across countries and the rise by 25 percentage points among a few participants suggested that the curriculum could be overall effective in enhancing knowledge. In Uganda, the average pre-test score of 84% with a modest post-test increase of 5 percentage points may be due to the overall high level of knowledge of a relatively homogeneous group of service providers. In contrast, the Nigerian participants scored on average lower and had a modest post-test increase. With a third of participants having a lower post-test score, the overall performance in Nigeria could have been affected by the inadequate mix of community health extension workers, who do not provide uterine evacuation services, with other providers as well as post-workshop fatigue and reporting error considering the perceived complex and “bulky” set of questions. However, the fact that around half of the participants were community health extension workers (and one radiologist!) likely biased the results: they did not constitute the appropriate audience, which likely reduced their training self-efficacy and knowledge and skills retention [ 40 ]. Community health workers can play a critical role in preventing unsafe abortion and could have benefited from a curriculum that ensured better training utility and skills transfer. Such a curriculum could include, for instance, essential information for community awareness and mobilization, values clarification and attitude transformation, and even eligibility assessment for early medical abortion using a standardized checklist as demonstrated by the WHO [ 41 ]. The mismatch between participants and curriculum underscored the importance of offering the appropriate training to the right audience especially in resource-limited humanitarian settings.

Fourth, the recommendations summarized in Fig. 1 were valuable in improving the training module before its finalization. Although some of the recommendations may appear ordinary, especially for development settings, organizing and running capacity building events in humanitarian settings often face constraints in terms of security, time, material, and human resources. Immediate and longer-term transfer of learning may be influenced by a core set of factors, no matter the context [ 42 ]. Some of these factors emerged positively from the evaluation (acquisition of knowledge and skills, perceived relevance, attitudinal change, motivation, and confidence). Others, such as the in-clinic availability of supplies, materials, or job aids, should be improved to facilitate trainees’ autonomy to create opportunities to use their skills in health facilities.

Finally, the S-CORT approach relies on master trainers to travel to humanitarian settings. Traveling to the field, where trainees work, is a requirement but a significant limitation of the model, especially when movement restrictions are due to insecurity or infection control measures—the COVID-19 pandemic is an illustration of the latter [ 43 ]. In consequence, our model should adapt and integrate different training options that favor self-learning and remote teaching and mentoring through a blended approach. However, these mobile strategies rely on information technology and electronic platforms that may not be widely accessible to service providers working in humanitarian settings and would require further research. While uterine evacuation using medication may be suitable for mobile learning, manual vacuum aspiration requires hands-on coaching. Mobile learning applications or modules should not suffer from a reductionist view that only promotes a mobile platform and neglects the complex relationship between adult learning principles and technology [ 44 ]. Therefore, the development of future mobile learning strategies should also be underpinned by proven learning approaches, including collaboration, reflection, building on prior experiences, and focusing on improving practice instead of evaluation [ 45 ].

Uterine evacuation is a lifesaving intervention, and access to these services has been a significant gap in humanitarian settings. When the lack of skilled human resources is a barrier to services, the S-CORT strategy could offer a rapid hands-on refresher training opportunity for service providers needing an update, and, therefore, contribute to achieving the implementation of the MISP. Such a capacity-building approach could be useful in humanitarian and fragile settings as well as in development settings with limited resources, however, only within an overall effort to strengthen other building blocks of the health system—a system that meets the SRH needs and rights of women, girls, and the whole community.

Availability of data and materials

Data is available upon reasonable request from the corresponding author.

Abbreviations

Democratic Republic of Congo

Minimal Initial Service Package for Sexual and Reproductive Health in Humanitarian Settings

Manual Vacuum Aspiration

Sexual and Reproductive Health Clinical Outreach Refresh Training

Sexual and Reproductive Health

Values Clarification and Attitude Transformation

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Acknowledgments

We thank all the workshop participants for their time and contributions.

This project was funded by the Government of the Netherlands.

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Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia

Nguyen Toan Tran

Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1206, Genève, Switzerland

Nguyen Toan Tran & Burim Vranovci

Training Partnership Initiative of the Inter-Agency Working Group on Reproductive Health in Crises, Women’s Refugee Commission, 15 West 37th Street, New York, NY, 10018, USA

Nguyen Toan Tran & Alison Greer

Federal Medical Centre, Keffi, Nasarawa State, PMB 1004, Nigeria

Talemoh Dah

Save the Children International DRC, 16 Avenue Avenue des Ecoles, Quartier les Volcans, Commune de Goma, North Kivu, Democratic Republic of the Congo

Bibiche Malilo

CARE International DRC, Kinshasa, Democratic Republic of the Congo

Bergson Kakule, Thérèse Faila Morisho & Douglass Kambale Asifiwe

CARE International Nigeria, 289 Amolai Road, GRA, Maiduguri, Nigeria

Happiness Musa & Japheth Simon

Save the Children, 899 N Capitol Street, NE, Washington, DC, 20002, USA

Janet Meyers

CARE USA, 151 Ellis Street NE, Atlanta, GA, 30303, USA

Elizabeth Noznesky

Doctors of The World/Médecins du Monde, France Headquarters, 62 rue Marcadet, 75018, Paris, France

Sarah Neusy

Ipas, P.O. Box 9990, Chapel Hill, NC, 27515, USA

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NTT, AG, and BP conceived the evaluation tools. BM, TD, BK, DKA, AM, JS, SN, and BP contributed to roll-out the in-country pilots with the support of JM, EN, and AG. TFM, BK, HM, JS, BP, SN, and TD collected the data with the support of BM, JM, EN, and AG. NTT, AG, BV, and BP conducted the analysis. NTT, AG, BV, and BP drafted the initial manuscript. All authors contributed to manuscript revision and have approved the final version.

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Correspondence to Nguyen Toan Tran .

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The workshop evaluations were part of planned program monitoring, which was not designed to develop and contribute to generalizable knowledge and therefore did not constitute research and require ethical approval (Royse D, Thyer BA, Padgett DK, 2009)—this was confirmed by our submission to the Western Institutional Review Board (No. 2633824–44635729). No patient participated in the evaluation.

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Tran, N.T., Greer, A., Dah, T. et al. Strengthening healthcare providers’ capacity for safe abortion and post-abortion care services in humanitarian settings: lessons learned from the clinical outreach refresher training model (S-CORT) in Uganda, Nigeria, and the Democratic Republic of Congo. Confl Health 15 , 20 (2021). https://doi.org/10.1186/s13031-021-00344-x

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Received : 19 October 2020

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DOI : https://doi.org/10.1186/s13031-021-00344-x

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Worldwide, an estimated 25 million unsafe abortions occur each year

Worldwide, 25 million unsafe abortions (45% of all abortions) occurred every year between 2010 and 2014, according to a new study by WHO and the Guttmacher Institute published today in The Lancet . The majority of unsafe abortions, or 97%, occurred in developing countries in Africa, Asia and Latin America.

“Increased efforts are needed, especially in developing regions, to ensure access to contraception and safe abortion,” says Dr Bela Ganatra, lead author of the study and a scientist in the WHO Department of Reproductive Health and Research.

“ When women and girls cannot access effective contraception and safe abortion services, there are serious consequences for their own health and that of their families. This should not happen. But despite recent advances in technology and evidence, too many unsafe abortions still occur, and too many women continue to suffer and die .”

Classifying abortion safety

The new Lancet study provides estimates on safe and unsafe abortions globally. For the first time, it includes sub-classifications within the unsafe abortion category as less safe or least safe. The distinction allows for a more nuanced understanding of the different circumstances of abortions among women who are unable to access safe abortions from a trained provider.

When abortions are performed in accordance with WHO guidelines and standards, the risk of severe complications or death is negligible. Approximately 55% of all abortions from 2010 to 2014 were conducted safely, which means they were performed by a trained health worker using a WHO-recommended method appropriate to the pregnancy duration.

Almost one-third (31%) of abortions were “less safe,” meaning they were either performed by a trained provider using an unsafe or outdated method such as “sharp curettage”, or by an untrained person albeit using a safe method like misoprostol, a drug that can be used for many medical purposes, including to induce an abortion.

About 14% were “least safe” abortions provided by untrained persons using dangerous methods, such as introduction of foreign objects and use of herbal concoctions. Deaths from complications of unsafe abortion were high in regions where most abortions happened in the least safe circumstances. Complications from “least-safe” abortions can include incomplete abortion (failure to remove all of the pregnancy tissue from the uterus), haemorrhage, vaginal, cervical and uterine injury, and infections.

Restrictive laws associated with high rates of unsafe abortions

The study also looks at the contexts that commonly result in women seeking unsafe abortions, including countries’ laws and policies on abortion, the financial cost of accessing safe abortion services, the availability of safe abortion services and trained health providers, and societal attitudes toward abortion and gender equality.

In countries where abortion is completely banned or permitted only to save the woman’s life or preserve her physical health, only 1 in 4 abortions were safe; whereas, in countries where abortion is legal on broader grounds, nearly 9 in 10 abortions were done safely. Restricting access to abortions does not reduce the number of abortions.

Most abortions that take place in Western and Northern Europe and North America are safe. These regions also have some of the lowest abortion rates. Most countries in these regions also have relatively permissive laws on abortion; high levels of contraceptive use, economic development, and gender equality; as well as high-quality health services – all factors that contribute to making abortion safer.

“Like many other common medical procedures, abortion is very safe when done in accordance with recommended medical guidelines and that is important to bear in mind,” says Dr Gilda Sedgh, co-author of the study and principal research scientist, Guttmacher Institute.

“In the high-income countries of North America and Western and Northern Europe, where abortion is broadly legal and health systems are strong, the incidence of unsafe abortions is the lowest globally.”

Among developing regions, the proportion of abortions that were safe in Eastern Asia (including China) was similar to developed regions. In South-Central Asia, however, less than 1 in 2 abortions were safe. Outside of Southern Africa, less than 1 in 4 abortions in Africa were safe. Of those unsafe abortions, the majority were characterized as “least safe.”

In Latin America, only 1 in 4 abortions were safe, though the majority were categorized as “less safe,” as it is increasingly common for women in the region to obtain and self-administer medicines like misoprostol outside of formal health systems. This has meant that this region has seen fewer deaths and fewer severe complications from unsafe abortions. Nevertheless, this type of informal self-use of medication abortion that women have to resort to secretly does not meet WHO’s safe abortion standards.

Preventing unsafe abortion

Unsafe abortion occurs when a pregnancy is terminated either by persons lacking the necessary skills/information or in an environment that does not conform to minimal medical standards, or both.

To prevent unintended pregnancies and unsafe abortions, countries must make supportive policies and financial commitments to provide comprehensive sexuality education; a wide range of contraceptive methods, including emergency contraception; accurate family planning counselling; and access to safe, legal abortion.

Provision of safe, legal abortion is essential to fulfilling the global commitment to the Sustainable Development Goal of universal access to sexual and reproductive health (target 3.7). WHO provides global technical and policy guidance on the use of contraception to prevent unintended pregnancy, on safe abortion, and the treatment of complications from unsafe abortion.

Earlier this year, WHO and the Population Division of the United Nations Department of Economic and Social Affairs launched a new, open-access database of laws, policies and health standards on abortion in countries worldwide . The database aims to promote greater transparency of abortion laws and policies, as well as to improve countries’ accountability for the protection of women and girls’ health and human rights.

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Research Article

Lived experiences and drivers of induced abortion among women in central Uganda

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Visualization, Writing – original draft

* E-mail: [email protected] , [email protected]

Affiliation School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda

Roles Data curation, Formal analysis, Methodology, Validation, Writing – review & editing

Affiliation Guttmacher Institute, New York, NY, United States of America

Roles Conceptualization, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing

Roles Conceptualization, Data curation, Investigation, Methodology, Validation, Writing – review & editing

Roles Conceptualization, Data curation, Investigation, Methodology, Project administration, Supervision, Writing – review & editing

Roles Data curation, Investigation, Methodology, Writing – review & editing

Affiliation Rakai Health Sciences Program, Rakai, Uganda

Roles Conceptualization, Data curation, Investigation, Methodology, Resources, Validation, Writing – review & editing

• Simon Peter Sebina Kibira, 
• Melissa Stillman, 
• Fredrick E. Makumbi, 
• Margaret Giorgio, 
• Sarah Nabukeera, 
• Grace Kigozi Nalwoga, 
• Elizabeth A. Sully

• Published: December 6, 2023
• https://doi.org/10.1371/journal.pgph.0002236
• Peer Review
• Reader Comments

Although unsafe abortions are preventable, they are one of the leading causes of maternal mortality and morbidity. Despite the serious potential health consequences, there is limited published information about drivers and challenges of obtaining abortions in restrictive settings such as Uganda. This limits efforts to improve programing for preventing unsafe abortion and providing comprehensive post abortion care. This study sought to understand the drivers and explain the lived abortion experiences among women from central Uganda, in an effort to promote greater access to safe reproductive healthcare services, and reduce unsafe abortions. This qualitative study included 40 purposely selected women who self-reported an abortion, living in Kampala and greater Rakai district, Uganda. They were part of a larger survey using respondent driven sampling, where seed participants were recruited from selected facilities offering post-abortion care, or through social referrals. Data were collected from May to September 2021 through in-depth interviews. Audio data were transcribed, managed using Atlas.ti 9, and analyzed thematically. The findings show that the underlying drivers stemmed from partners who were unsupportive, denied responsibility, or had raped/defiled women. Career and education decisions, stigma and fear to disappoint family also contributed. Women had feelings of confusion, neglect, betrayal, or shame after conception. Abortion and post-abortion experiences were mixed with physical and emotional pain including stigma, even when the conditions for safe abortion in the guidelines were satisfied. Although most women sought care from health facilities judged to provide safe and quality care, there was barely any counselling in these venues. Confidantes and health providers informed the choice of abortion methods, although the cost ultimately mattered most. The mental health of women whose partners are unsupportive or who conceive unintendedly need consideration. Abortion provided psychological relief from more complicated consequences of having an unplanned birth for women.

Citation: Kibira SPS, Stillman M, Makumbi FE, Giorgio M, Nabukeera S, Nalwoga GK, et al. (2023) Lived experiences and drivers of induced abortion among women in central Uganda. PLOS Glob Public Health 3(12): e0002236. https://doi.org/10.1371/journal.pgph.0002236

Editor: Sreeparna Chattopadhyay, FLAME University, INDIA

Received: April 18, 2023; Accepted: October 20, 2023; Published: December 6, 2023

Copyright: © 2023 Kibira et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and Supporting Information files.

Funding: The study on which this article is based was made possible by a grant from The David and Lucile Packard Foundation (2020-69738 to The Guttmacher Institute). The views expressed are those of the authors and do not necessarily reflect the positions and policies of the donors. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Reproductive autonomy, or the ability for people to decide and control their own contraceptive use, pregnancy and childbearing, is an essential human right. However, this is not the case for many women, with global estimates indicating that nearly half (121 million) of pregnancies that occur annually are either mistimed or unwanted [ 1 ]. While evidence suggests that global rates of unintended pregnancy have declined over time, the proportion of unintended pregnancies ending in abortion has increased [ 2 ]. The most recent estimates suggest that more than half of unintended pregnancies end in induced abortion, and the global abortion rate between 2015 to 2019 was 39 abortions per 1,000 women of reproductive age (WRA) 15–49 years [ 2 ]. Abortion is a common health intervention that should be safe, if conducted using methods appropriate to the duration of the pregnancy as recommended by the World Health Organization by a person with the necessary skills [ 3 ]. Yet, nearly half of abortions that occur are unsafe [ 1 , 4 ], with the largest burden occurring in the developing countries where it is highly restricted. Unsafe abortion remains a preventable, yet leading cause of maternal mortality and morbidity [ 5 ].

Despite the global decline in unintended pregnancies, the most recent national survey in Uganda indicated that the proportion of all most recent pregnancies/births considered unintended has increased to 46% (33% mistimed and 13% not wanted at all) in 2021 [ 6 ], from 41% in 2016 [ 7 ]. The problem of unintended pregnancy persists, partly due to a lack of access to sexual and reproductive health services and information, and limited use of any method of contraception. In Uganda, only 41.4% of all women aged 15–49 years are using a contraceptive method [ 8 ]. Contraceptive use rates have been rising at only about 1.2% per annum among all women since 2014 [ 6 , 8 – 10 ], with high 12-month discontinuation rates [ 7 , 11 ]. In 2021, 15% of all reproductive aged women and 26% of those in union were estimated to have an unmet need for family planning, meaning they did not want to become pregnant within the next two years but were not using any contraceptive method [ 6 , 11 ].

A 2013 study estimated an abortion rate of 39 per 1,000 women of reproductive age (WRA) in Uganda [ 12 ], although recent modelling estimates have shown even higher figures (43 per 1000 WRA) [ 13 ]. The high nationally and sub populations rates of abortion [ 14 ] are not surprising given the rise in unintended pregnancy rates [ 11 ]. Abortion in Uganda is only allowed in specific cases such as severe maternal illness threatening the health of pregnant woman, HIV positive women requesting termination, rape, incest and defilement [ 15 ]. This is in line with the Maputo protocol that only requires States parties to take all appropriate measures to protect the reproductive rights of women by authorizing medical abortion in cases the above circumstances [ 16 ]. In Uganda post abortion care is not restricted and must be given to women irrespective of the cause or abortion status [ 15 ]. However, even though well provided under the African Union and National guidelines, the negative attitudes and deep social stigma [ 17 – 20 ], including among health workers [ 21 ] may complicate access to safe abortion and/or post abortion care services [ 19 , 22 , 23 ]. These issues need to be brought to light of policy makers, and program managers to drive up evidence informed decision making to minimize or eliminate unsafe abortions. Unsafe abortions are costly to Uganda’s health system, with high expenditures on post abortion care [ 12 , 21 , 24 ], and deaths.

Given the highly restrictive nature of abortion in Uganda [ 21 ], there is limited information about the challenges that women inducing abortions face. This lack of evidence poses substantial challenges to provision and improvement of post abortion care programing. The purpose of this paper therefore was to understand the drivers of induced abortion and to explain the lived abortion experiences of women from central Uganda. We believe that lessons can inform the efforts to promote greater access to safe reproductive healthcare services, reduce unsafe abortions, and ultimately contribute to reduction of maternal morbidity and mortality in Uganda and other abortion restrictive settings.

Ethics statement

The study was approved by Makerere University School of Public Health Research and Ethics Committee (protocol 921), the Guttmacher Institute’s Institutional Review Board, and the Uganda National Council for Science and Technology (SS814ES). All participants provided written informed consent. Interviews were conducted in complete privacy—in spaces that the participants considered safe, in some cases away from their communities as preferred. A token of 20,000 UGX (USD 5.5) was provided to each participant as approved by the research and ethics committees. All interviews were conducted following an approved COVID 19 risk mitigation plan, observing the guidelines provided by the Uganda Ministry of Health. SPSK, SN and GKN had access to personal identifying information of the participants during data collection, but kept it confidential in a separate file away from the data transcripts and audio files.

Design and sampling

A mixed-methods study was conducted in greater Rakai and Kampala city, in central Uganda in 2021. Kampala represented a purely urban setting, while greater Rakai represented a mix of rural and peri urban settings. The current paper is based on a qualitative approach to study lived abortion experiences among 40 women (19 in Kampala city and 21 in greater Rakai areas). These respondents were purposely selected from a respondent-driven sample (RDS) of 411 women whose eligibility criteria included: living in the study areas, having reported an abortion within the last 6 years from 2021, and aged 15–49 years at the time of the study. The RDS recruited respondents through identifying initial seeds from selected facilities offering post abortion care services in each site. Using a standard recruitment script, facility providers approached and asked women about their willingness to join the study. Willing women (potential seeds) were then provided with phone numbers of the study team, and they called in voluntarily, after leaving facilities. The providers did not influence recruitment. Recruited seeds were provided up to three coupons by the study team, with contact information to recruit other women from their social network whom they knew met the set criteria, and who they thought would voluntarily want to share their abortion information for this study. A written recruitment script was provided to the women to ensure use of standard procedures. All women were screened by the study team to ensure they met the criteria before admission into the study. A subset of these women, following the survey who were willing to share further information about their experiences were invited for follow up discussions after the survey to share their abortion experiences in-depth. A stratified purposive sample mixed with maximum variation of the quantitative sample characteristics was applied. We aimed to balance the two strata (study sites). However, following daily research team debriefings, we reached thematic saturation by the 18 th respondent in Kampala, hence the slight imbalance between the two strata. Then, although not in equal numbers, the team also varied the sample by age, education levels, abortion methods used, sources, and experience with abortion (repeat and first-time abortion) to obtain views from a variety of experiences.

Data collection

A team of four experienced female research assistants were trained to conduct the in-depth interviews. They were trained and supervised by SN, GKN, FM, and SPSK. The training included a session about values clarification to minimize bias in collecting abortion data. All four had a minimum of a Bachelor’s degree, certification in conducting research with human subjects, and had engaged in more than five studies before. The first interview for each interviewer was reviewed to improve the interview tools, especially for the probing questions. Regular virtual debrief meetings were held between the research assistants and the investigators (SPSK, SN, GKN, FM), to ensure smooth data collection. All in-depth interviews were audio recorded, with women’s written consent. They lasted an average of 1hr and 12 mins. An in-depth interview guide was used with topics including how information regarding abortion is spread within social networks, factors related to their decision to abort, and their experiences with the most recent abortions throughout the process. Because participants were recruited from the survey respondents, data were collected for research purposes over several weeks; from 19 th May to June 17 th 2021, and then August 1 st to September 1 st 2021. There was an involuntary break between 18 th June and 31 st July 2021 due to the second wave of COVID-19 travel restrictions in the country.

Data management and analysis

After each interview, audio files were submitted to the study coordinator for safe custody. The audios were transcribed verbatim and simultaneously translated into English, from Luganda, the local language. The transcripts were checked for completeness by the study coordinator and stripped of any identifying information, and audio files were deleted after confirming completeness. We used both deductive and inductive approaches to code the data; a sample of transcripts were read to develop a codebook, which was also informed by thematic areas from the interview guide. The transcripts were imported into Atlas.ti 9 for final coding using the draft codebook, allowing for further open coding. Two persons including SPSK were involved in the coding to minimize possible biases from a single view. Query reports and codes document tables were produced to aid the writing of the findings. The synthesized findings presented in this paper include excerpts of raw data as typical quotations. The paper is written following the consolidated criteria for reporting qualitative studies. A completed COREQ checklist is attached as supplementary file ( S1 Table ).

Inclusivity in global research

Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the S1 Checklist .

Characteristics of participants

Table 1 summarizes the participants characteristics. The average age of the women was 28 years, with three quarters (75%) aged between 20 to 34 years. A third of women were in union (32.5%) while 42.5% had separated from partners. Majority had attained secondary or higher education level. Sixty percent had a child before the most recent abortion. Most (87.5%) women had the recent abortion from a health facility/clinic using medication abortion or surgical methods. For 70% of the women, this was their first abortion, and more than two thirds had the abortion within 2 years of the study. Most women had worked within the last 3 months.

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https://doi.org/10.1371/journal.pgph.0002236.t001

Fig 1 , summarizes the mapping of the findings from this study. It reflects what the 40 women reported to influence their decision to abort, experiences when they became pregnant before aborting, the sources of information during the period leading up to abortion, the influences of their choices for abortion methods used and the places to go, and the challenges experienced during and after abortion.

Mapping of experiences and drivers of abortion in greater Rakai and Kampala, Uganda.

https://doi.org/10.1371/journal.pgph.0002236.g001

Drivers of abortion

Partner and relationship-related drivers..

The main drivers of abortion were linked to unstable or challenging relationships and male partner’s behavior exhibited soon after being informed about the pregnancy. Most women reported that the male partner was not supportive, when informed about the pregnancy. Worse still, 32.5% of the women reported that the men denied responsible for the pregnancy, or indicated that they were not interested (7.5%). This was reported by women in varied relationship types; cohabiting, long distance, and who had casual or one-off sexual relations. Some men abandoned their partners after receiving the pregnancy news, and moved to unknown places. Some were physically and psychologically abused in their relationships, and could not imagine conceiving in such circumstances. Even in cases where a few women became pregnant in relationships with several misunderstandings, these situations worsened when the pregnancy was announced.

I conceived around September 2020 because by the time I aborted in February it was almost making five months. Honestly, I really did not want to because I conceived willingly. But when I conceived we got serious misunderstandings with my husband. The situation was not good, the man was a teacher, from Mbale [Eastern Uganda]. When we had misunderstandings, it seems he had issues at his workplace too, so he left the job and went back to his birth place. He did not call, and when I called, he did not answer and eventually blocked my number. I then used my friend’s phone to call him but whenever he heard my voice, he switched off. He left knowing I was two months pregnant because we did a pregnancy test at a clinic together. I imagined how to survive in such a condition. Then I thought of aborting when he left, but I thought that he will change his mind because there was no reason not to… I was terminated from work too while pregnant. So, I asked myself, “What I am I going to do with the pregnancy?” I don’t know the home of the man or any of his relatives. Even if I call, he does not care. I was forced to abort. Participant 11_Rakai, age 25

Unique to Rakai site, a third of the women there, reported that they and their confidantes aborted because the man responsible for the pregnancy was not their main partner at the time. They anticipated further complications in their unions after this. In one case the main partner had suspected he was not the father, and the respondent’s choice was abortion. One woman was still in a grieving period; just days after losing a partner, and got pregnant with a brother-in-law who offered ‘support’ during this time. It was complex for her to report such a pregnancy immediately after the husband’s death.

I missed my periods then I started feeling feverish, so I went and bought the pregnancy test kit, then I tested myself only to find I was pregnant. I informed my husband. Then he said, ‘that is impossible. I am not responsible for that pregnancy.’ The fact was that he was not responsible, I had got it outside of marriage…I knew where I had got that pregnancy, I thought it would look weird, maybe I would continue with the pregnancy and give the child to my husband. But already he had denied it, so I decided to have an abortion. Participant 20_Rakai, age 39

Financial drivers.

Where women reported the partners to be irresponsible, the financial strain and inability to care for the pregnancy and later the child, complicated the situation, in both study sites. The women without paid work or with meagre erratic incomes from casual work, could not imagine taking care of the pregnancy. Some, both young and older women, were already strained with the burden of having other young children.

The truth is that I did not have enough money to care for it [pregnancy/child], so I decided to abort. But, before then, my heart would say ‘please leave it’, yet it continued to grow and the man’s [responsible partner] manners continued to worsen. Actually, he eventually switched off his phone. Participant 11_Rakai, age_25

Personal decision drivers.

A quarter of all women stated that they had an abortion simply because they did not want the pregnancy at the time. Nine women were still students at the time they got pregnant, and abortion was the only way to continue their education.

Sincerely I did not want the pregnancy right away, because I did not wish to get pregnant I think I would have strangled the baby myself after birth [if she had not successfully aborted] Participant 3_Rakai, age 18

Other reasons included the fear of disappointing parents or guardians among young people still living with their guardians, a stressful work environment that was not ideal for pregnancy and fear of losing their job as a source of income, among those engaged in work. Some got pregnant from rape by family-friends or employers, or through incest; one woman conceived by the uncle.

My father had his best friend who used to come home often, and even stay over. I used to prepare food for them, and mum had already left [separated]. One-day he came home. When I finished washing and prepared food, I went to take a bath, but I found him in the sitting room after. I went to the bedroom to dress up and he followed me. He raped me from the bedroom and left. I was still young [on 14 years]… So, after three months I started feeling bad. I was feeling weak, lost appetite, I wanted to sleep all the time…It was in November when I learnt I was pregnant. I was in the compound then felt headache, felt dizzy, I collapsed. I gained consciousness while in the school sickbay. Then I asked the nurse what had happened to me. She asked if I had ever had sex. She told me I was pregnant… I was feeling ashamed… I wasn’t fat at that time, I was small but tall. I could not imagine people seeing me pregnant at 14 years, then they say that girl misbehaved at that age. Participant 7_Rakai, age 16

Feeling after confirming pregnancy

Women were asked how they felt after confirming the pregnancy prior to their most recent abortion. Many felt bad and confused, because the pregnancy was not intended. Some reported initially feeling positive, but after losing the support of the partners or significant others, the feelings towards the pregnancy changed. These women reported that they would have carried the pregnancy if such care was guaranteed. There were also feelings of shame and self-blame, especially in cases of conception outside the union or after rape/incest. A few women were ambivalent of the next steps at the time when they learnt about the pregnancy. One woman reported feeling suicidal tendencies at the time.

Before testing I was not feeling well and when I confirmed the feeling became worse. I said to myself that I have no job, I have no permanent place of residence. I came [to the city] to look for money, I have a school going child, I don’t know what to do. I tried calling him [partner] so that we would meet and talk… When we met, he told me that “I am not interested in giving birth at the moment”. I asked him what I should. His response was; ‘you know better.’ I went back thinking that it was a joke or the response was out of fear. I called again, he never picked my calls, I called several times without any response. What would I have done? Someone was housing me with my child. I had just got my job. My next step was to abort. When I consulted my friends they also advised to abort. I didn’t intentionally do it and that is why I told you that if you have somewhere to stay, please settle and give birth to your children. It is not good to abort… I was patient thinking that he would change his mind, I waited and waited but I was becoming weak. I could vomit everything I ate, getting out of the house was hard for me yet I had to work. Participant 2_Kampala, age 42

Choosing the appropriate location/provider for an abortion

Half of the women reported that they got information about where to go through their social networks. Women learned from their friends who had used the same facilities before, or already knew where to obtain the abortion prior to getting pregnant; through knowing someone who worked there or (for one women) had worked in the same facility themselves.

This friend of mine was already a friend to him [health worker]. I wonder whether she had aborted before. She was taking there many people. The health worker was well known for conducting abortions, they always have their phone numbers. Actually, she just called and told him I would like to bring my sister…So, she directed me and escorted me too…. I wasn’t aware of any other place. I didn’t know anywhere. Participant 4_Rakai, age 28

A third of the women sought information about where to obtain an abortion on their own in order to maintain privacy and prevent information leaking in their community. Some went to health facilities for a pregnancy test after missing their menstrual period, and while there, they discussed abortion as an option, and received referrals to place that could provide. Others searched for information without stating that it was them who needed to abort.

Okay that one [traditional healer] was my friend because she knew us from childhood. I could hear about her as an old woman who usually gives out herbal medicine. So, I thought that because she is a herbalist, she might be knowing these medicines to use. That is why I went to her. I deceived her that it was my friend who needed the herbs. Participant 11_Rakai, age 25

A few found out where they could abort from through family, including their sisters, and although rarely reported, through the mother and/or partner.

When I confirmed to him [partner] that I agreed to abort, I asked him where I should go. He directed me to the health center…There is a health worker that he had connected me to. I went to him and he told me to lie on the bed and he inserted the pills. Participant 8_Kampala, age 33

In choosing where to obtain their abortions, nearly half of the women prioritized places with skilled health care workers and available equipment. Skilled healthcare workers were indicative of good care, for some women. Although the availability of equipment was not always known, women used indicators like the size of the facility to assume they had equipment. Over a third of women chose a place based on their judgement of the ability to offer privacy. This was either through offering abortion together with general services, or because they were not frequented by people, and/or far enough from their community to minimize any recognition. Privacy also included the environment in the procedure room; women chose places where there was visual and auditory privacy. The cost of a place was also used to choose places.

What enticed me was the availability of a doctor, very professional and he also works in known hospitals. I selected it because when things fail at his facility, he could easily refer me to the next level. I also went there for privacy, I wanted to be treated from a health facility and come out well without my partner at home knowing what had transpired. All I wanted was to be in the hands of a trained personnel… I went to two clinics; the first one was asking for 100,000UGX, the second one my friend who had accompanied me was known there, so I told them that I didn’t have money and they reduced the cost. Participant 2_Kampala, age 42

Choice of methods

Over two thirds of the women reported procuring abortion services from the health facilities using medication abortion or surgical procedures. For medication abortion, they obtained what they described as “tablets” from pharmacies on their own, at clinics and inserted by the providers, or brought to their home by the confidantes. None of the respondents specified the brand names of the tablets. Surgical methods were obtained at clinics, but most women could only describe the process and appearance/ shape of equipment used.

For some, their method choice was based on previous experiences that was more painful, thinking they would have less pain with a new method; from surgical to medication. Others were advised by their confidantes on the ‘best’ method based on what they knew. A few women only went to seek abortion services at facilities or (in one case) were taken by a partner and did not know what method to use, but relied on the provider’s choice.

I refused surgical procedures because it is what I used for my first abortion and it was so painful. This time they explained to me that there was a method that was not painful. He [male partner] had also told me about it. … They used pills, there are tablets that they inserted in me and the rest I put them under the tongue. I went back home. They told me go back home and sleep. It will come out. I thought that I would just feel it coming out but it was so painful. Eventually it came out. Participant 8_ Kampala, age 33 We went in and I was injected on my thigh and then terminated it [pregnancy]… They just brought something like a tube and they inserted it there, you feel it inside here while outside here he is sucking / pulling it out. The pain was too much, it was so painful because I had never done it before. Participant 9_ Rakai, age 18 I lay on the bed then he came in with some equipment on a tray. I didn’t see what they were. He told me to widen my legs then inserted some equipment and I felt as if he was pumping something… I felt everything he was doing; the pain was too much. I held his arm. He told me ‘do not hold my arm, do you want me to spoil an organ here?’ Let me to do what am supposed to do.’ But I was in pain. Participant 12_ Rakai, age 34

Other women chose traditional methods including herbal abortifacients. These were known through referrals to traditional providers by confidantes who had used them. There were also several women who simultaneously used modern (medication) and the herbs for abortion. Others used the herbs to help with the post abortion effects including managing pain and what they referred to as “cleansing the uterus” after abortion. The most used herb for cleansing the uterus was “kamunye” [Hoslundia opposita]. Others included commelina africana , and phytolacca dodecandra . Among users of herbal abortifacients, there were reported complications that needed further assistance from the health centers, clinics, or pharmacies.

I knew about them [herbal plants] , but I didn’t know where to get them from . I knew there was herbal medicine but the specific type was chosen by her called ‘luwoko’ [phytolacca dodecandra] and she brought it for me , but we know these things . There’s another herb called ‘ennanda’ [commelina africana] which we insert in our private parts , to terminate a pregnancy . Participant 1_Kampala , age 37 I shared with my friend and she told me about a woman who gives herbs. I took them and by 6pm abdominal pains had started, then after it came out. I saw that something had come out so I quickly to cut it and it fell down then I got up, padded and stayed there for a week. But when I came back, I noticed some things remained inside although I was walking… I went to hospital and told them that I had a miscarriage but there are things that remained inside. Participant 5_Rakai, age 38

Challenges experienced during and after abortion

Respondents reported physical, financial, emotional, and psychological challenges during and after the abortion process. These included physical pain and lethargy, experience of stigma, financial strain, and psychological distress. Some reported using ineffective methods resulting in incomplete abortions that negatively impacted an already challenging situation. Even those who did not directly experience these consequences of abortion, several expressed fear of stigma, social judgment, exposure of their secrets by partners, and disappointing the family.

Physical challenges.

Most women, regardless of age, location and abortion methods used, reported experiencing extreme pain during the abortion process and the period directly after. There were varied coping mechanisms following the onset of pain including swallowing pain killers to medicinal herbs.

I experienced very bad side effects . If my friend did not come early in the morning , the effects might have worsened…I do not understand these tablets [for medication abortion] because I experienced terrible abdominal pains at night from about 2am , and I thought I was going to die inside the house . But , I had already swallowed them and there was nothing to do . In the morning , I started bleeding very much and I got worried again that I was going to die inside the house , which would be shameful . Then the foetus came out but there was a problem within my uterus , which I did not know about . It was later that I started experiencing more pain . I consulted my friend and she brought ‘Kamunye’ [Hoslundia opposita] to drink…However , I realized that tummy was swelling and I told my friend that ‘you know what let me go to hospital because there appears something that might not be right . ’ At the hospital , I was told that if the swelling had increased beyond , I would have died . I had clots in various places and so if I had not gone to the hospital , the medical officer told me I would have died because many women have died like that . Participant 7_Kampala , age 31

Financial challenges.

Women reported financial strain with some not being able to afford their preferred methods of abortion. Beyond abortion services, there were costs related to managing the post abortion care, like buying sanitary pads, pain killers and post abortion care services at facilities, in case of incomplete abortion.

I was afraid of them [tablets] but my money would afford that because the other method was costlier. They were going to suck out the fetus and it cost 100,000/ = yet I had only 50,000shs.’ Participant 17_Kampala, age 24

Several women relied on partners who promised to provide financial support but backtracked, forcing them to seek alternative support from friends or relatives.

It was a clinic. I told him [health worker] that I didn’t have the money and he asked ‘how much can you afford?’ I told him 30,000/ =. He laughed and said ‘I can help you do it at 50,000/ = but with no extra medicine given’. So I had to look for the 50,000/ = which took time to get because I was not working. It is my friend and my niece who contributed to get the 50,000/ =, which we paid to the provider to conduct the abortion, but he didn’t give me any tablet. After the abortion, he said ‘you go and whatever happens do not tell me.’ We went home but I had too much pain the whole night then the fetus came out in the morning, it was about three months old because we took over a month to get the money. The bleeding was too much, I would take boiled herbs, I was so dizzy. My friend would come and buy me millet flour, sometimes cassava flour for porridge, until God helped me to recover. Participant 12_Rakai, age 34

Psychological and emotional challenges.

Women also reported suffering psychologically for a long period after the abortion. A few younger women and those aborting for the first time, as well as the few who conceived from rape and incest, faced challenging psychological distress. Misperceptions about the consequences of abortion also worsened the psychological distress.

I cried and regretted that I will never do it again. I wished I had given birth. The pain worsened every time I thought about it. During conferences, they advised us not to abort because it is a bad omen and one may never conceive again. Whenever I listened to that, I felt guilty, it would hurt… I got scared that I might fail to conceive and I made a promise to only get married after I become pregnant. I wanted to get married after confirming that I can conceive, but I failed my own promise, because I ended up aborting again. Another thing was seeing my breasts sagging while other girls were firm. I felt bad losing my beauty yet I could not tell any of the girls that I aborted. Participant 9_Kampala, age 25

Although rarely reported, there was fear for stigmatization due to abortion, with some young women experiencing it in the community. They hid from community members, friends, family, and housemates, endeavoring to conceal evidence that could breed suspicion. They feared to disappoint family, especially parents. One woman feared to report the history of abortion while seeking care for her current one, because of perceived judgment from a provider.

A certain gentleman in our village told me that, ‘you are deceiving, you are not sick, you are not suffering from fever, you say the truth that you aborted, someone can tell, you are not like that usually.’ They told me that I had an abortion. Participant 15_Rakai, age 18

There were women who used ineffective methods resulting in complications and at times incomplete abortions. Some women, at the time of the study still suffered what they thought were the effects from the methods used. They also reported that they knew other women who experienced similar consequences. These psychologically affected their quality of life.

I used herbs and eventually had a foul smell from my private parts, which took time to clear… After I got a discharge, it doesn’t smell nor itch but I have it [to date] and I cannot disclose to people, I keep quiet and suffer in silence. Participant 18_Rakai, age 33

For a few women, the process of aborting at the health facilities/clinics, was daunting. The fear of what was going to happen and the equipment to be used, which they had not heard about or seen, coupled with a lack of counselling complicated some experiences.

He said I am going to use some equipment, but you must be strong, then I was wondering how the equipment work, I was in great fear. They [tools] can really scare. Have you ever had tooth extraction? The chairs in the dentist room! So, when I got to this room there was a certain smell, the chairs had a funny shape, you feel as if you are in hell, you feel ‘yes, it is time to die’. The health worker mixed medicine, he was preparing his machines, I was all shivering… and by the time he attended to me, honestly, I was feeling the [perceived] pain. Participant 19_Rakai, age 25

Abortion helped avoid worse consequences

Although women reported enormous challenges in the process, for most, abortion provided a sense of relief from the expected consequences of having an unplanned birth. Most said they would have given birth but expected a more complicated life. For those still in school, it would spell the end of their education, and those with informal jobs, the end of their work.

Schooling would have stopped at that and I think I would not have sat for senior six. I would have ended there but the child would be alive. Participant 6_ Kampala, age 25

The most feared consequence was the financial strain resulting from having a pregnancy and a(another) child, yet many were already living in hard financial situations. Abortion provided an option to circumvent these potentially worse problems. Statements like ‘ no one would have supported me ,’ ‘ I would be back in the village suffering ’ or ‘I would have lost my job ’ were common.

I don’t know what would have happened because I was finished . I was going to hustle with that pregnancy yet I had no help . I already have two other children here and they are still young and yet I am the father and I am the mother at the same time . I would be pregnant without any help . Let me not lie to you , it would have been so bad… when I aborted and returned in my normal state , I began working for these other [three] children , because I am the mother and the father .. Participant 3 , Kampala_age 28 Of course, I would be suffering…because you do not have the Child’s father, and even the first child is in the same state (fatherless)…You won’t be able to buy a mattress, you won’t buy smearing oil, you won’t buy clothe because all the children are your responsibility. How do you think you would feel? Participant 21, Rakai_age 38

There were also health and other social consequences anticipated in case no abortion was done. Women living with HIV could not imagine the additional burden of pregnancy, while fending for other children. A few adolescent girls and young women imagined the impact on their future marital relationships if they had a child, and those whose partners were unsupportive imagined no one who would have cared for them.

I can’t regret, the termination helped me so much because whenever someone is pregnant there are changes in terms of health yet I have to work, I have to work… I don’t know but it would have been a very difficult financial and health situation. Health wise I have to take ARVs, then the pregnancy, so health wise too, it wouldn’t have been easy. These two conditions and the stress too yet I have to take care of the family. Participant 12, Rakai_age 34 A lot would happen it would be the end of the world. I was small I think I would lose more weight. Sincerely you face a lot of challenges; where to stay, in case they chase you away from home, where do you go? Who could accommodate me? The nurse [that was helping her] was also married with children and renting. The world can come to an end before me and you die or commit suicide. Participant 7, Rakai_age 16

This study provides an exploration of abortion drivers and lived experiences of women obtaining abortion in central Uganda. For most women, the underlying drivers were partner related; including being involved with partners who were either financially or emotionally unsupportive, and/or who denied responsibility for the pregnancy. For some, the pregnancy was a result of violence, rape, defilement or incest. Such women did not want to have a child in such a relationship, but if circumstances were favorable, they would have carried the pregnancy. Some women reported terminating their pregnancy in order to salvage a career or education path; some also expressed that the shame and stigma around their pregnancies as well as the fear of disappointing family after conceiving contributed. Women expressed negative experiences after confirming pregnancy, with feelings of confusion, neglect, betrayal by loved ones, shame after rape or incest or pregnancy from infidelity. Abortion and post abortion experiences were mixed with physical and emotional pain in addition to realized or feared stigma. Most women sought abortion care from formal facilities that they deemed safe and able to provide quality care, with skilled providers and equipment available. Choices of the method and place were based on recommendations by confidantes, and affordability, but providers also played a role in method choice while at the facility. However, very few women reported any pre or post abortion counselling; an essential component of safe abortion care. Lacking supportive information and counseling services, women did not know what to expect from the abortion process and reported pain and confusion around their experiences. Many, based on misinformation, were concerned about the longer-term consequences of their abortions. Amidst these complex experiences however, many women reported feeling psychologically relieved when they hypothesized what the social and financial situation would have been if they had a (another) child.

Although the main drivers of abortions are expected to stem directly from unintended pregnancies [ 21 ], as was the case with a quarter of the women in this study, the reasons women have abortions are more nuanced. A common theme in our study was that for most women, the underlying drivers of the decision came from external factors, often partner related. Similar findings regarding partner influence have been reported before [ 25 , 26 ]. Men play an important role in women’s health decisions [ 23 ] especially in patriarchal settings like Uganda with limited women’s empowerment and/or reproductive autonomy. One’s paternity determines a sense of belonging in Uganda because naming of a child follows the father’s line. Carrying a pregnancy in cases where the man denies responsibility or is untraceable is daunting and has many ramifications for women. This tradition makes it complex and may result in stigma for the child born with no defined father figure and therefore no clear lineage. Abortion as seen in this study may be the ‘best’ option for a woman to counter the lasting effects of such denials. While most women cited partner-related issues in their decision to abort, they did not rely on their partners for support; rather, they turned to their confidantes for help or chose to navigate the experience alone. With unsupportive partners, the financial complexities played a big role in the abortion decision, as evidenced elsewhere [ 27 ]. Costs like transport and distance impact on abortion decisions and place where to, even in more developed settings [ 28 ]. The cost of abortion and post abortion care for many was financially taxing in this study. Some could not afford the preferred methods, and others sought support of friends and/or relatives, in cases of uncooperative partners. This has also been reported in another study in Kampala and Mbarara, Uganda [ 19 ].

Our study also shows that stigma and shame surrounding unintended pregnancy drive abortions. Young women especially expressed fear to disappoint their family when they became pregnant. The expectations placed on children as the future of the family in many cases is well known. Thus, any disappointment resulting from pregnancy has far reaching effects, including the shame that the family especially in rural well-connected communities may experience. Another study in Ghana among adolescents indicated similar social influence [ 29 ]. A few women in our study had experienced rape and/or incest and could not explain this to the family and community, or live with the baby that resulted from such an experience. Sexual abuse like defilement in which the culprit is a family member (incest) is secretly handled in many settings to minimize shame on the family. In such cases, the victims suffer silently to ‘protect’ the family name and seek abortion with minimal support. Women expressed confusion, feeling of neglect, betrayal by loved ones, and shame after pregnancy from rape, incest or infidelity. Others were uncertain about next steps. With negative attitudes rife in the community, several women were uncertain about what the family or community would think about their decision. The pre and post abortion periods were lonely or with only close confidantes. Although not explicitly reported in this study, the heavy religious prohibitions of abortion [ 30 ], in all circumstances, as part of the tradition, may also have shaped the pre and post abortion experiences. Previous studies have reported secrecy as part of abortion [ 26 ] and society judgement from religious leaders expecting women to carry pregnancies, even in conditions like rape [ 30 ], defilement or incest.

Some women in the Rakai site aborted because they had conceived with another man outside the union and were scared of the consequences. An earlier study in central and western Uganda revealed restrictive abortion attitudes, with men believing a woman can only abort where conception is not from the main partner [ 19 ]. Women in this study sometimes sought abortion clandestinely even when they had conceived through rape or incest, or tested positive for HIV while pregnant. Yet, all these would have qualified for safe and legal abortion services under the national guidelines [ 15 ].

In this study, most women sought care from the formal health facilities using medication abortion or surgical methods. This shows that even in settings where most abortions are carried out clandestinely because of restrictions, women can and do access safer abortion services. Most women seeking care in health facilities looked out for skilled providers expected to provide quality care, assumed availability of equipment to support the abortion, and to offer privacy. The choice of what method to use was based on mainly recommendation by confidantes in the social networks who had aborted.

Past experiences also counted for those who had repeat abortions. The role of the provider was brought to light in this study, with some women noting the method used was decided by the provider. However, ultimately the cost mattered, given that many had financial constraints; some choosing a place or method that wasn’t the first choice. Although rarely reported, traditional methods like herbal abortifacients were used. Several women also reported trying to use both a modern (often medication abortion) method in combination with herbal. Herbs were also used to manage post abortion complications or “cleansing the uterus” after. In an earlier study in Uganda, Prada et al [ 31 ], also reported several herbs as well as dangerous objects were used in abortion, especially among rural women.

Challenges during and after abortion were enormous for women in this study. Most reported excruciating pain in the process and some because of incomplete abortions using ineffective methods. Women experienced psychological distress as a result of the abortion experience and in some cases partners’ threats to disclose their abortion. The post abortion stigma and social judgement [ 20 ] and the disappointment of the family was often feared, living in worry of being discovered and deciding to isolate or be less social. This supports the view that although abortion may be a private matter, it can have social ramifications as indicated in another study among men in western Uganda [ 32 ]. Self-blame and lasting regrets even after successful abortions were rife, some still wishing they had not aborted. The lack of counselling in health facilities before and after abortion could have complicated the experiences. Given the limited awareness and ambiguity in implementing abortion care guidelines, abortions tend to be clandestine in nature. Providers and women may therefore aim to quicken the process, in fear, further worsening the experiences. Although Uganda is signatory to the Maputo protocol where States parties are required to take all appropriate measures to provide adequate, affordable and accessible health services, including information to women especially those in rural areas [ 16 ], there is a clear gap as evidenced in this study.

Although the abortion experience was challenging for all women in the study, it is worth noting that many felt psychologically relieved when they imagined what the consequences would have been if they kept the pregnancy and had a(another) child. Relief from further financial strain, the ability to look after the children they already have, and the ability to continue with their education was paramount. However, this relief only came after having to navigate an undesirable and difficult abortion experience, in most cases without much support.

The strength of this study is that we obtained lived experiences from women across two varied settings, a city and a peri-urban location. The study participants were purposely selected from a large diverse survey sample of women with a recent abortion. This provided maximum variation of views from multiple demographic and social backgrounds. The study has some limitations. Because we started recruitment of seeds in the RDS at post abortion care facilities, this may have resulted in having more women in the sample receiving facility-based abortions. All women were recruited from RDS, so the views in our qualitative data does not include women who did not disclose their abortions to others, and who may be more isolated in their experiences.

Implications

This study has a number of implications for policy and programming. There is need to raise awareness about the reasons for abortion. Abortion- and pregnancy-related stigma leads women to seek abortion clandestinely, which means some women seek abortion from untrained providers or use ineffective or unsafe methods (even under conditions where abortion should be legally provided for). Stigma also adds to the psychological distress many women experience throughout their abortion, so addressing abortion stigma is central to improving women’s abortion and post abortion experiences.

The awareness of National abortion guidelines among women seeking abortion and healthcare providers, including under what conditions and where women can access legal services needs to be given attention. There should also be community awareness on what to expect from an abortion, how to recognize post abortion complications, where and when to seek treatment.

There should be emphasis on counseling training as part of post abortion and safe abortion care training, including sharing information to combat misperceptions about the consequences of abortion.

Conclusions

Partner relations are the most impactful factors contributing to abortion among women in this study; when they do not provide financial and emotional support after conception, deny responsibility or leave women to bear the brunt alone. Rape, defilement or incest should not be underestimated as a cause of unintended pregnancies and resulting into abortion, with culprits going unpunished. The stigma and fear to disappoint family after conceiving and the self-blame even in circumstances that women have no control over, like rape, also contributes to unsafe abortion.

The confidantes in women’s social network play a crucial role recommending methods and places to seek abortion care. With limited awareness in their network about guidelines for legal abortion, decision to seek abortion and post abortion care may also be impacted.

The abortion and post abortion experiences are unpleasant in restrictive settings, even when conditions for safe abortion are satisfied. The mental health of women whose partners are unsupportive or who conceive unintendedly needs consideration. Yet, there was barely any pre and post abortion counselling. Although undesirable, abortion provided psychological relief from consequences of bearing an unintended child in complex situations.

Supporting information

S1 checklist. inclusivity in global research..

https://doi.org/10.1371/journal.pgph.0002236.s001

S1 Text. Excerpts from the transcripts.

https://doi.org/10.1371/journal.pgph.0002236.s002

S1 Table. Consolidated criteria for reporting qualitative studies checklist.

https://doi.org/10.1371/journal.pgph.0002236.s003

Acknowledgments

The authors are grateful for the support received from partners at Rakai Health Sciences Program and Reproductive Health Uganda; Joseph Kagaayi, Kenneth Buyinza and Edward Kiggundu. We also thank the research assistants who collected the data; Resty Nakayima, Prossie Aliwebwa, Sheila Kisakye, and Margaret Nansubuga. We are indebted to the women who shared their personal sensitive and touching stories.

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Complications of unsafe abortion: a case study and the need for abortion law reform in Nigeria

Affiliation.

• 1 Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Lagos, Nigeria. [email protected]
• PMID: 12369323
• DOI: 10.1016/s0968-8080(02)00024-1

Complications of unsafe abortion account for 30-40% of maternal deaths in Nigeria. This paper reports a case of unsafe abortion by dilatation and curettage, carried out by a medical practitioner in a private clinic on a 20-year-old single girl in Lagos, Nigeria. The girl was 16 weeks pregnant. She suffered complications consisting of perforation of the vaginal wall through the utero-vesical space into the abdominal cavity with gangrenous loops of small intestine herniating through it. Information was obtained from her case notes and the operating theatre register. She had a resection and anastomosis of the small intestine and had to remain in hospital, where she made a full recovery, for two weeks. Unsafe abortion is fraught with many complications, including pelvic sepsis, septicaemia, haemorrhage, renal failure, uterine perforation and other genital tract injuries, and gastro-intestinal tract injuries. Where expert, emergency treatment for these is not available, women die. Unsafe abortion procedures, untrained abortion service providers, restrictive laws and high morbidity and mortality from abortion tend to occur together. We advocate for a review of the existing restrictive laws in Nigeria in order to reduce the high morbidity and mortality from unsafe abortion.

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• Complications of unsafe abortion in South West Nigeria: a review of 96 cases. Abiodun OM, Balogun OR, Adeleke NA, Farinloye EO. Abiodun OM, et al. Afr J Med Med Sci. 2013 Mar;42(1):111-5. Afr J Med Med Sci. 2013. PMID: 23909102
• Making abortions safe: a matter of good public health policy and practice. Berer M. Berer M. Bull World Health Organ. 2000;78(5):580-92. Bull World Health Organ. 2000. PMID: 10859852 Free PMC article. Review.
• Time to Resumption of Menses, Spatial Distribution, and Predictors Among Post-partum Period Women in Ethiopia, Evidence From Ethiopian Demographic and Health Survey 2016 Data: Gompertz Inverse Gaussian Shared Frailty Model. Belay DG, Asratie MH. Belay DG, et al. Front Reprod Health. 2022 May 13;4:862693. doi: 10.3389/frph.2022.862693. eCollection 2022. Front Reprod Health. 2022. PMID: 36303667 Free PMC article.
• Why do married women procure abortion? Experiences from Ile-Ife, south western Nigeria. Ojo IE, Ojo TO, Orji EO. Ojo IE, et al. Afr Health Sci. 2021 Mar;21(1):327-337. doi: 10.4314/ahs.v21i1.42. Afr Health Sci. 2021. PMID: 34394314 Free PMC article.
• Unsafe abortion practices and the law in Nigeria: time for change. Akande OW, Adenuga AT, Ejidike IC, Olufosoye AA. Akande OW, et al. Sex Reprod Health Matters. 2020 Dec;28(1):1758445. doi: 10.1080/26410397.2020.1758445. Sex Reprod Health Matters. 2020. PMID: 32458762 Free PMC article. No abstract available.
• Narratives of women presenting with abortion complications in Southwestern Nigeria: A qualitative study. Oyeniran AA, Bello FA, Oluborode B, Awowole I, Loto OM, Irinyenikan TA, Fabamwo AO, Olutayo L, Ganatra B, Guest P, Fawole B. Oyeniran AA, et al. PLoS One. 2019 May 29;14(5):e0217616. doi: 10.1371/journal.pone.0217616. eCollection 2019. PLoS One. 2019. PMID: 31141550 Free PMC article.
• Pattern and outcome of induced abortion in abakaliki, southeast of Nigeria. Ikeako L, Onoh R, Ezegwui H, Ezeonu P. Ikeako L, et al. Ann Med Health Sci Res. 2014 May;4(3):442-6. doi: 10.4103/2141-9248.133475. Ann Med Health Sci Res. 2014. PMID: 24971223 Free PMC article.

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• Volume 4, Issue 3
• Unsafe abortion and abortion-related death among 1.8 million women in India
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• Ryo Yokoe 1 ,
• Rachel Rowe 2 ,
• Saswati Sanyal Choudhury 3 ,
• Anjali Rani 4 ,
• Farzana Zahir 5 ,
• http://orcid.org/0000-0003-0660-5054 Manisha Nair 2
• 1 Nuffield Department of Population Health , University of Oxford , Oxford , UK
• 2 NPEU, Nuffield Department of Population Health , University of Oxford , Oxford , UK
• 3 Department of Obstetrics and Gynaecology , Guwahati Medical College and Hospital , Guwahati , India
• 4 Department of Obstetrics and Gynaecology , Institute of Medical Sciences, Banaras Hindu University , Varanasi , India
• 5 Department of Obstetrics and Gynaecology , Assam Medical College , Dibrugarh , India
• Correspondence to Dr Manisha Nair; manisha.nair{at}npeu.ox.ac.uk

Introduction Unsafe abortion is a preventable cause of maternal mortality. While studies report high number of abortions in India, the population-level rates of unsafe abortion and their risk factors are not well understood. Our objective was to analyse the rates of and risk factors for unsafe abortion and abortion-related maternal death in India.

Methods We conducted a secondary analysis of data from 1 876 462 pregnant women aged 15–58 years from nine states in the Indian Annual Health Survey (2010–2013). We calculated the rate of unsafe abortion and abortion-related mortality with 95% CI. Multivariable logistic regression models examined the associations of sociodemographic characteristics, health seeking behaviours and family planning with unsafe abortion and abortion-related mortality.

Results There were 89 447 abortions among 1 876 462 pregnant women in 2007–2011 (4.8%; 95% CI 4.8 to 4.9). Of these, 58 266 were classified as unsafe (67.1%; 95% CI 66.7 to 67.5). There were 253 abortion-related maternal deaths (0.3%; 95% CI 0.2 to 0.3). Factors associated with unsafe abortion: maternal age 20–24 years (adjusted OR (aOR): 1.13; 95% CI 1.09 to 1.18), illiteracy (aOR: 1.48; 95% CI 1.39 to 1.59), rural residence (aOR: 1.26; 95% CI 1.21 to 1.32), Muslim religion (aOR: 1.16; 95% CI 1.12 to 1.22), Schedule caste social group (aOR: 1.08; 95% CI 1.04 to 1.12), poorest asset quintile (aOR: 1.45; 95% CI 1.38 to 1.53), antenatal care (aOR: 0.69; 95% CI 0.67 to 0.72), no surviving children (aOR: 1.30; 95% CI 1.16 to 1.46), all surviving children being female (aOR: 1.12; 95% CI 1.07 to 1.17), use of family planning methods (aOR: 0.69; 95% CI 0.66 to 0.71). Factors associated with abortion-related deaths: maternal age 15–19 (aOR: 7.79; 95% CI 2.73 to 22.23), rural residence (aOR: 3.28; 95% CI 1.76 to 6.11), Schedule tribe social group (aOR: 4.06; 95% CI 1.39 to 11.87).

Conclusion Despite abortion being legal, the high estimated prevalence of unsafe abortion demonstrates a major public health problem in India. Socioeconomic vulnerability and inadequate access to healthcare services combine to leave large numbers of women at risk of unsafe abortion and abortion-related death.

• risk factors

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjgh-2019-001491

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Key questions

What is already known.

There is a high prevalence of unsafe abortion in India, but population level rates and risk factors are not clearly understood.

What are the new findings?

67% of abortions in the study population in India were classified as unsafe, varying widely across the states (range 45.1%–78.3%).

There was a disproportionately higher risk of unsafe abortion among the vulnerable and disadvantaged populations in India.

Young women aged 15–19 years were at the highest risk of dying from an abortion-related complication.

What do the new findings imply?

Urgent work is needed to understand the barriers to safe abortion in India, despite the conducive legal environment.

Introduction

Unsafe abortion is one of the preventable causes of maternal mortality 1 yet, of the 55.7 million abortions that occurred globally each year between 2010 and 2014, an estimated 25.1 million (45.1%) were unsafe. 2 Defined by the WHO as “the termination of an unintended pregnancy either by persons lacking the necessary skills or in an environment lacking the minimum medical standards or both,” 3 unsafe abortion is strongly associated with maternal complications such as haemorrhage, sepsis and trauma, and is the fourth leading cause of maternal death. 4 Abortion plays a crucial role in the reproductive health of Indian women. 5 An estimated 15·6 million abortions (14.1 million–17.3 million) were conducted in India in 2015. Women in India often turn to unqualified providers for abortion, 6 despite abortion being made legal in the country through the Medical Termination of Pregnancy Act in the early 1970s. 7 While several studies suggest a high prevalence of unsafe abortion and related complications among women of reproductive age group in India, 2 6 8 9 population-level rates of unsafe abortion and abortion-related mortality, and their risk factors are not well understood.

Previous research and theoretical arguments on abortion in India point to three main and interrelated factors that are important in understanding the context of seeking abortion: (1) women’s labour force participation and educational attainment; (2) women’s social class and ethnicity; (3) the predominant preference for male children. 10 However, the combined effect of these factors has not been tested empirically. This is crucial to identify populations that are at a higher risk of seeking unsafe abortion in India to prevent maternal complications and deaths. The objectives of this study were to: (1) estimate the rates of unsafe abortion and abortion-related maternal mortality in nine states in India; (2) examine the sociodemographic characteristics of women who have an abortion compared with women who have a live birth; (3) investigate the risk factors for unsafe abortion; (4) investigate the risk factors for abortion-related maternal death in India.

We conducted a secondary data analysis of the 2010–2013 round of India’s Annual Health Survey (AHS) to analyse the rate of and risk factors for unsafe abortion and abortion-related maternal deaths in nine states in India.

Definitions

Based on the WHO definition, we used three criteria to identify ‘unsafe abortions’ using AHS data: (1) the setting where the abortion was performed (if induced) or completed (if spontaneous); (2) the person who performed or completed the abortion; (3) the gestational age at which the abortion was performed or completed. Abortions were classified as unsafe if they were not performed or completed in a health facility, not performed or completed by a skilled birth attendant, or performed or completed at 20 weeks of gestation (~5 months) or beyond. Abortions at or beyond 20 weeks’ gestation were classified as unsafe because of the association with increased risk of maternal morbidity and mortality 11 and because abortion beyond 20 weeks of pregnancy is illegal in India and under such a condition woman may be forced to seek abortion services from unqualified providers. The breakdown of unsafe abortion according to the three criteria is presented in online supplementary table S1 .

Supplemental material

We combined induced and spontaneous abortion into one category to minimise the risk of misclassification 3 10 as most induced abortions are unreported or reported as spontaneous in surveys for legal, ethical and moral reasons. 12 13 Further, it was considered that determining safety of abortion was more important than examining types of abortion. Rees et al have argued that both induced and spontaneous abortion can result in unsafe abortion and present with complications. 14

Data source

We used AHS (2010–2013) data. The AHS is a population-based household survey in which self-reported data on maternal and child health, demographics, birth and access to health and family planning services were collected from 4.3 million households in nine less developed states of India (Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand and Assam), representing 50% of the country’s population, 61% of births and 62% of maternal deaths. 15 16 The AHS used a stratified simple random sampling (without replacement) to obtain a sample that was representative of and proportional to the size of the selected villages. Survey weights were developed to account for the sampling method. The survey administered four ‘schedules’ (or questionnaires): (1) House-listing Schedule, (2) Household Schedule, (3) Women Schedule and (4) Mortality Schedule. Relevant data from all four schedules were merged for this study. Detailed objectives and associated methodology can be found in the AHS Report (Part I. 2014). 16

Study sample

All women who provided information on their pregnancy (91.3% most recent pregnancy and 8.7% on a previous pregnancy) were included. As in a previous study using the same dataset, women who had an abortion after 28 weeks were excluded as these were most likely to be stillbirths (according to the WHO definition for stillbirth). 15 A total of 1 876 462 women who reported being pregnant during the reference period 2007–2011 were included in the study. The mortality data were extracted from the mortality Schedule of the AHS and 253 abortion-related deaths were included, giving a total of 89 447 abortions in 2007–2011. Among these, 253 women who died and 83 women who survived did not have information to examine the safety of abortion. Therefore, safety of abortion was examined in a total of 89 111 women, of which 58 266 had unsafe abortions and 30 845 had safe abortions. online supplementary figure S1 further illustrates how we derived the samples for each study objective.

Potential risk factors for unsafe abortion and abortion-related deaths

We conducted a systematic search and review of the literature to identify risk factors for unsafe abortion and abortion-related death. Informed by the literature review, we developed conceptual frameworks to map the relationships of the risk factors with unsafe abortion ( online supplementary file 1 ) and abortion-related mortality ( online supplementary file 1 ) according to proximity to the outcome, and to guide selection of variables and analysis. Based on the literature review and conceptual frameworks, we grouped the population characteristics/potential risk factors as sociodemographic characteristics, pregnancy-related characteristics, family characteristics, the use of family planning methods, and health seeking behaviours and mapped these against the available data in the AHS. We used survey data about household assets and principle component analysis 17 to derive a measure of household wealth which is thought to be a good proxy of economic status. 18 19 We used data about the number of surviving children and the number of female children to derive the proportion of surviving female children. We considered the following as potential risk factors for unsafe abortion and/or abortion-related death: use of family planning method; place of residence; social group; religion; asset index/wealth; number of total surviving children; proportion of female children; maternal age; maternal education status; antenatal care (ANC) use; marital status; maternal employment; gestational month of abortion. The variables and their categorisation are described in online supplementary file 1 . All independent variables reflect characteristics of the household or women at the point of the survey. Baseline groups were chosen as the group with the least potential risk of having unsafe abortion, except for the use of family planning methods and the use of ANC (baseline—higher potential risk).

Statistical analysis

There were three outcomes of interest: (1) the outcome of the woman’s pregnancy (live birth or abortion); (2) the safety of abortion (safe or unsafe); (3) the outcome of abortion (survived or died). The rate of abortion, unsafe abortion, and abortion-related death and the corresponding 95% CIs were calculated. The denominator for abortion rate was the total number of pregnancies in the reference period (2007–2011), and for the rates of unsafe abortion and abortion-related death was the total number of abortions during the same reference period. The characteristics of women who had an abortion were compared with those who had a live birth. We used univariable logistic regression analysis to examine the association between each independent variable and the outcomes (unsafe abortion and abortion-related mortality). Modelling a non-linear association between maternal age and the outcomes using fractional polynomials showed that maternal age acted in a non-linear fashion and was therefore used as a categorical variable.

Multivariable models were built using a stepwise forward regression approach, with our conceptual frameworks used to select the order for including the variables starting from distal to proximal ( online supplementary figures S2 and S3 ). During model building for unsafe abortion we used a p value <0.05 in the univariable analysis as a cut-off for including a variable. We used the Wald test at the 5% significance level to determine if adding a variable significantly improved the model fit. In the multivariable model examining the risk factors for abortion-related death we chose to include all six potential risk factors, regardless of the results of the univariable analysis, because the number of variables available in the mortality dataset was small, and in order to control for confounding effects. Factors whose effects were attenuated by other variables in the multivariable regression were further examined to identify confounding. We calculated the proportion of factors reported to contribute to abortion-related maternal death.

Collinearity between independent variables was explored using pairwise correlation coefficients. We tested for interactions between variables for which there was a strong theoretical rationale. In the risk factor analysis for unsafe abortion, we therefore tested for interactions between employment and residence, employment and wealth, and social group and wealth. In the risk factor analysis for abortion-related mortality, interactions between social group and wealth, and social group and residence were examined. Potential interactions observed using univariable logistic regression were further assessed using the Wald test comparing the multivariable model with the relevant interaction terms with an empty model. No significant interactions were found at the 5% significance level.

We carried out an exploratory post hoc subgroup analysis to investigate the effect of the number of surviving female children in households where all children were female on the odds of unsafe abortion. All statistical analyses were carried out using Stata V.13.1 using the ‘ svy set’ function to account for the stratified and clustered nature of the data. All proportions, means and CIs presented are therefore weighted for design effects and non-response. Two-sided p values <0.05 were taken to indicate statistical significance.

Missing observations per variable were quantified, and we explored the ‘type of missingness’ by generating a new variable indicating missing data for each risk factor followed by logistic regression analysis to identify factors that predicted missingness. Based on this analysis, data were assumed to be ‘missing at random’ and three methods were used to address bias due to missing data: missing indicator method, complete case analysis and multiple imputation. 20 The ‘missing indicator’ model in which missing data were grouped as a separate category was used as the final model. However, to maintain model stability, for variables that had <1% missing data, a separate category for ‘missing’ was not generated.

Study power

For the fixed sample size of 89 111 women who were classified as having a safe abortion and 58 266 who had an unsafe abortion, this study had 90% power to detect an OR of ≥1.29 or ≤0.75 associated with unsafe abortion at p<0.05 (two-tailed) for the risk factor with the lowest prevalence (‘other religion’ 0.6%), and an OR of ≥1.43 or ≤0.74 for the risk factor with the highest prevalence (‘being married’ 99.6%) in the study population.

For the fixed sample size of 89 447 women who had an abortion and survived and 253 women who died during or within 42 days of the abortion procedure, this study had 80% power to detect an OR of ≥3.00 associated with abortion-related death at p<0.05 (two-tailed) for the risk factor with the lowest prevalence (‘Christian religious group’ 0.6%), but not enough power to detect an OR less than one at a clinically meaningful level. This study had 80% power to detect an OR of ≥1.43 or ≤0.74 for the risk factor with the highest prevalence (gestational month of abortion <5; 99.6%) in the study population.

Patient and public involvement

This is not applicable since this was a secondary analysis of anonymous survey data.

Rate of abortion, unsafe abortion and abortion-related mortality

Among a total of 1 876 462 pregnant women in the study population, 89 194 women had an abortion leading to an overall rate of 4.8% (95% CI 4.8 to 4.9). The rate of abortion for each state is shown in table 1 . The prevalence of abortion was highest in Assam (6.5%) and the lowest in Chhattisgarh (1.6%). Out of 89 111 women who survived and had sufficient information to examine the safety of abortion, 58 266 women were classified as having an unsafe abortion. The overall rate of unsafe abortion was 67.1% (95% CI 66.7 to 67.5) with five out of nine states above the overall rate ( online supplementary table S3 , figure 1 ). There was a large variation in the rate across the states: Assam had the lowest (45.1%) and Chhattisgarh has the highest rate of unsafe abortion (78.3%). Among a total of 89 194 women who had an abortion, 253 were reported as abortion-related maternal death in the AHS, giving an abortion-related mortality rate of 0.3% (95% CI 0.2 to 0.3) ( online supplementary table S4 ).

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Number and rate of abortion in nine states in India, using the AHS 2012–2013

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Rate of unsafe abortion in nine states in India.

The characteristics of women who had an abortion and those who had a live birth are presented in table 2 . Overall, despite statistically significant differences because of the large sample size, there were no clinically meaningful differences in age, education, residence, religion or social class background between the two groups. Two factors showed wide variation between the abortion and live birth groups. While 85.1% of women who had a live birth reported having some ANC, only 23.1% of women who had an abortion had ANC. This was true even after excluding women who had an early abortion (<12 weeks). Also, a marginally higher proportion of women who had an abortion belonged to the highest quintiles of the asset index.

Characteristics of the study population by pregnancy outcome

Risk factors for unsafe abortion in India

The characteristics of the women who had an unsafe abortion and those who had a safe abortion are described in table 3 . All sociodemographic characteristics (except marital status and maternal employment status) and all other characteristics (except self-reported mental illness) were found to be statistically significantly associated with unsafe abortion, and these associations were not substantially altered after adjustment for all potential risk factors ( table 3 ).

Unadjusted and adjusted associations between sociodemographic and family characteristics, health seeking behaviour, family planning and unsafe abortion

Compared with women aged 25–29 years, the adjusted odds of unsafe abortion were 13% higher for younger women (20–24 years), and 18% lower for older women (35–39 and 40–44 years). Women living in rural settings had 26% higher odd of unsafe abortion compared with women living in urban settings. Muslim, Christian, or ‘other’ stated religion were associated with increased odds of unsafe abortion compared with Hindu. Education was inversely associated with unsafe abortion; women with no education were 48% more likely to have an unsafe abortion compared with women with university education or higher. Poorer women (in the lowest asset index quintile) had 45% higher odds of unsafe abortion, compared with women in the highest quintile.

In the univariable analysis, belonging to Schedule caste and Schedule tribe social groups was associated with a higher odds of unsafe abortion compared with the ‘other’ social groups. After adjusting for other risk factors the higher odds of unsafe abortion remained for the Schedule caste group, but for the Schedule tribe social group the association was reversed, with this group having 14% lower odds of unsafe abortion compared with the ‘other’ social group. Further analysis showed that the substantial change in the adjusted OR (aOR) was largely explained by the confounding effect of asset index (or wealth quintiles).

Women who had no children at the point of interview had a 30% higher odds of having unsafe abortion compared with women who had one to three children. Compared with women whose children were all boys, women with all female children had 12% higher odds of having an unsafe abortion. This association was not significant if the woman had at least one surviving male child. On further examination through a subgroup analysis, we did not find any significant association between the number of surviving female children and unsafe abortion in households with all female children.

After adjusting for other risk factors, reported use of family planning methods at the point of survey was associated with a 21% lower odds of unsafe abortion. Women who had used ANC had 31% lower odds of unsafe abortion compared with those who did not use ANC. The results of complete case analysis and multiple imputations were not materially different from the ‘missing indicator’ model ( online supplementary table S5 ).

Risk factors for abortion-related maternal deaths in India

Of the six potential risk factors investigated (maternal age, place of residence, religion, social group, wealth/asset index, gestational month), five were statistically significantly associated with abortion-related death ( table 4 ). We found a non-linear (U-shaped) association between mother’s age and abortion-related death ( online supplementary figure S4 ). Compared with women aged 25–29 years, the aOR for abortion-related death was approximately eight times higher for women aged <20 years, and two times and four times higher for women aged 40–44, and ≥45 years, respectively. Women belonging to a Schedule tribe social group were four times as likely to die during or after having an abortion compared with the reference ‘other’ social group, but the association was not statistically significant for women belonging to a Schedule caste social group (OR: 1.38; 95% CI 0.52 to 3.66). Living in rural areas was associated with a higher odd of abortion-related death (aOR: 3.28; 95% CI 1.76 to 6.11). While the results of our missing indicator analysis were not materially different from the other models, one notable difference was that in the complete case model women who had an abortion at a gestational age of ≥5 months had a significantly higher odds of dying compared with women who had an abortion before 5 months (aOR: 4.35; 95% CI 2.53 to 7.50) ( online supplementary table S6 ).

Unadjusted and adjusted associations between sociodemographic characteristics, gestational age at abortion and abortion-related maternal death

Further analysis of factors contributing to abortion-related maternal death showed that a third of the deaths were due to delays in receiving care at the health facility, 19% were due to inadequate care at health facility and 17% were due to a failure to recognise the seriousness of the condition ( online supplementary table S7 ).

Main findings

To our knowledge, this study is the first large population-based study to examine unsafe abortion and abortion-related morality in India. The overall rate of abortion was estimated to be 4.8%, ranging from 1.6% to 6.5% among the nine states. Overall, 67.1% of abortions were classified to be unsafe, varying widely across the states with the highest being 78.3% and the lowest being 45.1%. The overall rate of abortion-related death was estimated to be 0.3% and did not vary appreciably across the states.

There were no clinically meaningful differences between women who had an abortion and those who had a live birth, but a significantly lower proportion of the women who had an abortion had ANC, and a higher proportion were educated and belonged to higher socioeconomic status. We found a strong association of unsafe abortion with sociodemographic factors (younger maternal age, lower socioeconomic status, Muslim religion, rural residence, illiteracy, schedule caste social group), healthcare service utilisation (ANC), family characteristics (number of surviving children and proportion of surviving female children) and family planning use. We found that factors associated with unsafe abortions were different from those associated with abortion-related mortality. Teenage women (aged 15–19 years) were found to have the highest risk of abortion-related death in addition to rural residence and lower socioeconomic status.

Strengths and limitations

Use of data from the AHS, the largest health survey in India, allowed us to conduct an adequately powered, robust investigation of a wide range of potential risk factors. Our findings are reasonably generalisable for high burden states, but may not be generalisable to the rest of India. To our knowledge, this study is the first in India to identify risk factors associated with unsafe abortion and abortion-related death at a population level.

The rate of unsafe abortion and abortion-related mortality may be underestimated due to underreporting of abortion and misclassification of abortion-related death. Women are often reluctant to report induced abortion regardless of the legal context of abortion. 12 13 Similarly, women might have provided inaccurate information on the three criteria used to classify the safety of abortion. Since the cause of maternal mortality was reported by family members without validation, deaths occurring after having an abortion might have been misclassified as death caused by haemorrhage or pregnancy-related deaths. In an effort to minimise the possibility of misclassification between abortion and stillbirth, women who reported having an abortion after 28 weeks were excluded.

As the survey design was cross-sectional, causality cannot be inferred from the study results. We did not have data on the method of abortion, therefore this could not be used as a criterion for classifying the safety of abortion. However, methods used to estimate unsafe abortion rates vary widely across studies, 2 21–24 and there are discrepancies between how the WHO definition is worded and how it has been practically applied to measure the burden of unsafe abortion. 25 Because there were some factors identified in the literature as important risk factors for unsafe abortion (including, eg, sexual behaviour, partners’ approval of abortion, reasons for abortion, pregnancy wantedness and exposure to media), for which data from the AHS were not available, there is a risk of residual confounding. Finally, because death is a rare outcome, this study had restricted statistical power to detect significant associations between risk factors and abortion-related death.

Other evidence and implications

Our estimates of the prevalence of unsafe abortion in these nine Indian states fit with regional estimates from a study in south-central Asia (57.8%; 95% CI 50.3 to 65.9), 2 but are much higher than in a study conducted in India using data from the 2015 Health Facilities Survey and national abortion medication sales, which concluded that among 15.6 million abortions occurring in 2015, 0.8 million (5%) abortions were unsafe. 8 This discrepancy is possibly because in this latter study unsafe abortion was defined only as a surgical abortion performed outside of a health facility, without considering who performed the abortion or when the abortion was performed.

Our results suggest a pervading theme of vulnerability for unsafe abortion related to low socioeconomic status and teenage pregnancy. While there was an increased prevalence of abortion among educated women, the risks of unsafe abortion, and of death related to abortion, were higher among uneducated women, consistent with previous literature. 22 26 Although the prevalence of abortion was higher among women with higher socioeconomic status, women from lower socioeconomic status, and ‘Schedule caste’ social group, were more likely to have an unsafe abortion, and to die from abortion-related causes. This is consistent with evidence showing that disadvantaged minority groups in Brazil are at a higher risk of unsafe abortion. 22 Our finding that women belonging to ‘Schedule tribe’ groups were less likely to have an unsafe abortion might be explained by different health seeking behaviours in women from these groups or may have arisen due to residual confounding. Nevertheless, the risk of abortion-related death was higher in both social groups, indicating the possibility of disparities in access to adequate healthcare for management of abortion complications.

The importance of access to adequate healthcare is also highlighted by our findings on place of residence. Compared with women in urban settings, women living in rural settings were more likely to have an unsafe abortion and more likely to die from an abortion-related cause. More than half (56.28%) of the abortion-related deaths in this study were due to a lack of access to appropriate healthcare (ie, delay in receiving healthcare at facility, inadequate care at health facility and lack of transport to the facility). About 70% of India’s population live in rural settings, but safe abortion services are rarely available at rural facilities. 21 In the state of Rajasthan, for example, rural settings had an estimated 0.85 certified abortion facilities per 100 000 population, compared with 3.65 in urban settings. 27

Lack of access to appropriate health services is also reflected in our results in other ways. Our complete case analysis showed that gestational age at the time of the abortion was found to be one of the strongest risk factors for abortion-related mortality, which is consistent with the finding of one study conducted in the USA. 11 Although it was not possible to examine the safety of abortion among women who died, this variable serves as a proxy for unsafe abortion, supporting the evidence that an abortion-related death is most likely to occur after an unsafe abortion. 14 The process of seeking an abortion, or care for complications of spontaneous or induced abortion, can involve multiple visits to different providers, resulting in delays, with potentially devastating consequences. 28–30 In India, preventing unwanted pregnancies through family planning is a key strategy for reducing abortion rates. 31 32 Access to family planning services, may also be important for reducing the risks of having an unsafe abortion. 23 33 34 Finally, our results also suggest that antenatal check-ups may be important in reducing the risk of maternal morbidity and mortality resulting from complications, even if they plan to seek an abortion.

Beside socioeconomic factors, women’s age was significantly associated with unsafe abortion and abortion-related death. Younger women (≤24 years) were at a higher risk of unsafe abortion and risk of abortion-related death was highest among teenage women (15–19 years). Older women (≥30 years) were less likely to have an unsafe abortion, but were more likely to die as a result of an abortion. Other studies, in Bangladesh 26 and Nigeria, 35 found similar results in relation to maternal age and unsafe abortion. Although female selective abortion (FSA) is illegal in India, the practice is still prevalent. 36–38 Our finding that women with no male children were more likely to have an unsafe abortion compared with women who had at least one male child is consistent with FSA being sought from unregistered and unqualified abortion providers. 3 39

The high estimated prevalence of unsafe abortion in India demonstrates a critical public health problem. Consistent with research in other low-and-middle income countries (LMICs), our results demonstrate that socioeconomic vulnerability, teenage pregnancy and inadequate access to healthcare services combine to leave large numbers of women at risk of unsafe abortion and abortion-related death. There is an urgent need to ensure adequate access to family planning, early abortion services and adequate care for management of postabortion complications, particularly in disadvantaged areas. Further research providing empirical evidence on the barriers to safe abortion services in India is essential to reduce unsafe abortions and deaths, particularly in populations identified to be at a higher risk.

Acknowledgments

We thank Noon Altijani, DPhil student at the Nuffield Department of Population Health (NDPH) and Charles Opondo, Researcher in Statistics and Epidemiology, National Perinatal Epidemiology Unit, NDPH, for their help with survey commands and multiple imputation analysis, respectively. The AHS was conducted by the Office of the Registrar General & Census Commissioner, India ( http://censusindia.gov.in/vital_statistics/AHSBulletins/ahs.html ). We obtained the data from the Indian Government’s Data Sharing Portal where the anonymised data is freely available for research and other purposes.

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• World Health Organization DoRHaR

Handling editor Seye Abimbola

Contributors RY reviewed the literature, conducted the analysis and wrote the first draft of the manuscript. MN led the conceptualisation of the project, compiled the data, supervised the data analysis, interpretation and discussion of the results, and edited the paper. RR supervised the data analysis, interpretation and discussion of the results, and edited the paper. SSC, FZ and AR contributed to interpreting the data, and editing the paper.

Funding The study was funded by a Medical Research Council Career Development Award to Manisha Nair (Grant Ref: MR/P022030/1). The funder had no role in the study design, data analysis, data interpretation, or writing of the report. MN had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Competing interests None declared.

Patient consent for publication Not required.

Ethics approval The anonymised data are freely available through the Indian Government’s Data Sharing Portal.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement Data are available in a public, open access repository.

Read the full text or download the PDF:

Mental Health Implications of Abortion and Abortion Restriction: A Brief Narrative Review of U.S. Longitudinal Studies

Information & authors, metrics & citations, view options, mental health after abortion.

Mental Health After Abortion Versus After Denial of Abortion

Conclusions

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• Ann Med Surg (Lond)
• v.84; 2022 Dec

Suspected illegal abortion and unsafe abortion leading to uterine rupture and incomplete abortion: A case report

Ayush anand.

a BP Koirala Institute of Health Sciences, Dharan, Nepal

Ashwini Gupta

Punita yadav.

b Department of Obstetrics and Gynaecology, BP Koirala Institute of Health Sciences, Dharan, Nepal

Pappu Rijal

Associated data, introduction.

Unsafe abortions are more prevalent in developing countries and countries with restrictive abortion laws, and can lead to significant maternal mortality. Usually, the presentation includes abdominal pain, fever and vaginal bleeding.

Case presentation

We reported the case of a female in her twenties in her second trimester of pregnancy following unsafe abortion. The patient had abdominal pain, and laboratory investigations revealed anemia and leucocytosis. The patient opted for abortion as the foetus was identified as female by a service provider. Due to unsafe and illegal abortion, the patient developed complications of incomplete abortion and uterine rupture. She was successfully managed by emergency laparotomy followed by repair of uterine rupture and symptomatic management.

Clinical discussion

Unsafe abortion can lead to complications such as incomplete abortion and uterine rupture. Complications due to abortion are more frequent if not performed by experienced surgeons. In our case, the manual vacuum and aspiration technique was used during the second trimester of pregnancy, which led to uterine perforation.

Our case highlighted the importance of safe abortion practices and the approach to clinical management of complications of unsafe abortion. Also, global health problems such as unsafe abortion, illegal abortion, sex-selective abortion, and violation of ethical conduct need to be addressed to curb unsafe abortion.

• • Unsafe abortion can lead to incomplete abortion and uterine rupture.
• • MVA is recommended in the first trimester, and D&E is recommended in the second trimester.
• • It is essential to counter the trend of sex-selective abortion, particularly in developing countries.

1. Introduction

The global estimate by WHO revealed that 73 million induced abortions happen each year, of which nearly 45% are unsafe, and 97% occur in developing countries [ 1 ]. Asia, particularly South and Central Asia, constitute more than 50% of unsafe abortions [ 1 ]. A study revealed that approximately 7.9% of maternal mortality was due to unsafe abortions [ 2 ]. A study in Africa revealed that death due to unsafe abortions accounted for about one-third of all maternal mortalities [ 3 ]. These patients usually present with fever, abdominal pain, and vaginal bleeding [ 4 ]. Furthermore, it can lead to complications such as incomplete abortion, uterine rupture, and traumatic injury to the genital tract [ 2 , 5 ]. Hence, timely intervention is needed to prevent mortality. Herein, we present the successful management of a female in her twenties Gravida 3 Parity 2 Living 1 Infant death 1 at 19 weeks of gestation presenting with abdominal pain following abortion.

2. Presentation of case

2.1. presentation and history.

A female in her twenties Gravida 3 Parity 2 Living 1 Infant death 1 at 19 weeks of gestation presenting to Gynae Emergency with a complaint of pain abdomen for 11 hours. The pain was present over the whole abdomen, severe and started following the manual vacuum and aspiration (MVA) procedure performed at a local clinic. On further ienquiry, she said she visited a local clinic for gender determination, where the foetus was identified as a female. As the patient and her family members did not want to have a female child, she opted for termination of pregnancy at the same clinic. After the procedure, she was given some intravenous analgesics for pain relief and referred to our hospital. On the route to our hospital, she passed urine and flatus. There was no history of nausea, vomiting, fever, excessive vaginal bleeding, or loss of consciousness. The patient has been married for 12 years. In her first pregnancy, she had to undergo an emergency lower segment caesarean section (LSCS) for meconium-stained liquor and gave birth to a healthy female baby. Currently, the child is of 5 years. In her second pregnancy, she gave birth to a female child of 2.5 kg weight through elective LSCS. The child died at 6 months of age due to some unknown cause. The patient was not using contraceptives, and the medical history did not reveal any chronic illness in the patient and family members. There was no history of any drug allergies, alcohol consumption, smoking or recreational drug use.

2.2. Physical examination

On general examination, she had pallor. Her vitals were: blood pressure of 100/80 mm of Hg, pulse rate of 102 beats per minute, respiratory rate of 24 cycles per minute, spo2 of 98%, and the temperature was 98.8° Fahrenheit. On abdominal examination, mild tenderness was present in the left hypogastric region, and bowel sounds were heard. Her size of the uterus corresponded to 22 weeks period of gestation. The rest of the systemic examinations were normal. On per speculum examination, a gestational sac was felt through the external os with pieces of essential fat present. On per vaginal examination, the uterus was 20–22 weeks in size, and a gestational sac-like structure was felt.

2.3. Laboratory findings

The initial laboratory investigations ( Table 1 ) revealed anaemia and leucocytosis. Ultrasonography of the abdomen and pelvis revealed macerated foetus in the intrauterine cavity with no cardiac activity. Also, echogenic content was reported in the lower part of the endometrial cavity with posterior acoustic shadow; the posterior wall and right uterine wall were not delineated clearly. Ultrasonography could not rule out the possibility of uterine perforation.

Laboratory investigations of the patient.

2.4. Assessment and intervention

After reviewing the investigations, she was transferred to the operation theatre for emergency exploratory laparotomy. The procedure was performed at a tertiary care hospital by a senior consultant with more than ten years of experience. An epidural catheter and central venous pressure line were inserted. A midline vertical incision was given, and the abdominal cavity was opened in layers. Rent of 2 cm × 2 cm size was seen ( Fig. 1 ) on the posterior wall of the uterus through which a bowel loop entered the uterine cavity. The bowel loop was released from the uterine cavity and examined for any perforation or tear by the surgery team. There was no perforation or tear in the bowel. A small tear was present in mesentery with no bleeding. Then the bowel loop was placed into the abdominal cavity. After that, the foetus was removed along with the placenta. The removed foetus was identified as male. Uterus was closed with vicryl suture ( Fig. 2 ), followed by the closure of the rectus sheath with prolene suture. The skin was closed by applying stapler. An antiseptic bandage was applied, followed by vaginal toileting.

Uterine perforation (shown by arrow).

Repair of Uterine perforation (shown by arrow).

Tablet Misoprostol 800 μg was given per rectal. The patient was started on intravenous antibiotics Piperacillin plus Tazobactam 4.5 gm, Metronidazole 500mg, Ranitidine 50mg, Metoclopramide 10mg, Ketorolac 30mg, Paracetamol 1 gm were given three times a day. Also, Synthetic Oxytocin 20 Units in 3 pints of intravenous fluids was given. In addition, intravenous Ringer's Lactate 1 unit and 2 units of Normal Saline were given. She also received 1 pint of Whole Blood and 1 pint of Fresh Frozen Plasma. Then, the patient was shifted to the maternal intensive care unit, where she was kept under vigilant observation. She was kept nil per oral for 48 hours, and input and output charting was done.

2.5. Post-operative history

On her first post-operative day, she received intravenous potassium chloride 20 mEq in alternate 2 pints of intravenous fluids as she had hypokalaemia ( Table 1 ). Intravenous Ketorolac was given when required, and she received 1 pint of packed cell blood. Intravenous Synthetic Oxytocin was stopped. The patient was encouraged to ambulate. On her second post-operative day, the urinary catheter was removed, and the drugs were continued. All her intravenous drugs were discontinued on the fifth post-operative day, and she was switched to oral Levocetirizine 5 mg and Paracetamol 1 gm. She was discharged on her sixth post-operative day.

2.6. Follow up

On follow-up after one month, the patient was in good health and doing well.

3. Discussion

Across the world, various sociological factors determine the sex preference of a child by the parents [ [6] , [7] , [8] ]. The countries in South-East Asia have primarily been patriarchal societies [ 6 ]. Hence, having a male child is preferred in these countries [ [6] , [7] , [8] , [9] ]. Also, sex-selective abortion is rising globally, particularly in South-East Asia [ 1 , [10] , [11] , [12] , [13] ]. This leads to a skewed birth rate and can be detrimental to the population control policy. Furthermore, in countries that prohibit sex-selective abortion, couples can seek illegal options and abort the foetus [ 9 , 13 , 14 ]. The couples may take the help of service providers lacking the required skills, leading to unsafe abortion practices. Illiteracy, all children being female, and social shame was also associated with unsafe abortions [ 15 , 16 ]. In our case, the foetus was misidentified as female and she already had two female children from her last two pregnancies, motivating the patient to undergo an illegal abortion [ 17 , 18 ]. Moreover, safe abortion practices were not followed [ 15 ] This also highlighted gross negligence and violation of legal and ethical boundaries, which needs to be addressed to limit such incidents in the future.

Unsafe abortion can lead to incomplete abortion, haemorrhage, uterine perforation and damage to the genital tract [ 2 , 5 ]. Studies in Pakistan revealed that the maternal mortality from unsafe abortion was nearly 34.9%, with uterine perforation, septicaemia and gastrointestinal injury being the common complications [ 3 , 14 ]. A study in Nigeria revealed that abdominal pain, fever and vaginal bleeding were the most common presenting symptoms in unsafe abortions [ 4 ]. A study revealed that the incidence of uterine perforation following unsafe abortion by Manual vacuum and aspiration was around 0.4% in a hospital setting in India [ 19 ]. Another study revealed that the chance of surgical abortion failure was more if done by health providers other than doctors [ 20 ]. In our case, the patient presented with abdominal pain and the abortion was performed by an unskilled service provider through manual vacuum aspiration during the second trimester of pregnancy. The manual vacuum and aspiration technique is the surgical choice for medical termination of pregnancy during the first trimester [ 21 ]. During the second trimester, the surgical approach of Dilatation and Evacuation is preferred over the medical approach [ 22 ]. However, in our case, the manual vacuum and aspiration technique was used during the second trimester of pregnancy, which led to uterine perforation.

This work has been reported in line with SCARE 2020 criteria [ 23 ].

4. Conclusion

Our case highlighted the approach to management of complications of unsafe abortion such as incomplete abortion and uterine rupture. Also, we identified four major global health problems: increasing trend of sex-selective abortion in south-east Asia, unsafe abortion leading to maternal complications, breach of ethical code of conduct, and sociological factors contributing to illegal abortion. It is necessary to address these factors to counter the global health problem of unsafe abortion, particularly in developing countries. Efforts are required to counter the gender-based power imbalance through women empowerment. Also, the government should act to expand safe abortion facilities and take measures to ensure that healthcare providers provide the optimum quality of service.

Ethical approval

Ethical approval was not required for this case report.

Sources of funding

The authors did not receive any funding for this manuscript.

Author contributions

A.A. and A.G. drafted and critically revised the manuscript. P.Y. and P.R. critically revised the manuscript. All authors approved the final version of the manuscript and are accountable for all aspects of the work.

Registration of research studies

• 1. Name of the registry: N/A.
• 2. Unique identifying number or registration ID: N/A.
• 3. Hyperlink to your specific registration (must be publicly accessible and will be checked): N/A.

Punita Yadav is the Guarantor.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Consent of patient

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Declaration of competing interest

The authors have no conflict of interests to declare.

Acknowledgements

We would like to thank the patient for sharing detailed information.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.amsu.2022.104933 .

Appendix A. Supplementary data

The following is the Supplementary data to this article:

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Unsafe abortion: A preventable danger

Unsafe abortion is one of the five leading causes of maternal mortality, and the only one that is preventable.

• Democratic Republic of Congo
• Maternal health
• Safe abortion
• Unsafe abortion is a significant contributor to maternal mortality worldwide.
• Over 29,000 women and girls die annually due to unsafe abortion.
• People resort to unsafe abortion due to a lack of safe options and unbearable pregnancies.
• Legal limitations, moral judgment, and stigma can inhibit access to safe abortion care.

Unsafe abortion remains one of the five leading causes of maternal mortality, despite the fact that it is mostly preventable. In recent decades, the world has made significant progress in reducing many causes of maternal deaths—severe bleeding, severe infection, blood pressure disorders, and obstructed labor—yet there has been little improvement to diminish the dangers of unsafe abortion. 

Abortion, whether safe or unsafe, is a common event worldwide: one in six unintended pregnancies ends in abortion, and one in three of all pregnancies, including planned pregnancies, ends in an abortion. Forty-five percent of all abortions globally are deemed unsafe.

women and girls are injured or disabled due to unsafe abortions every year.

of all unsafe abortions occur in developing countries .

women and girls die as a result of unsafe abortions every year.

Unsafe abortion rates around the world

More than 29,000 people die each year due to unsafe abortion, the majority in developing countries across Africa, Asia, and Latin America—all regions where Doctors Without Borders/Médecins Sans Frontières (MSF) provides medical aid, including safe abortion care . Our teams treat women and girls harmed by complications from unsafe abortions every single day.

When a woman or girl is determined to end her pregnancy she will do so, regardless of the safety and legality of the procedure. Where safe abortion care is not available, she will often risk her life with an unsafe abortion because the prospect of continuing the pregnancy is unbearable.

Meanwhile, the scale of post-abortion complications is enormous, with an estimated seven million women and girls hospitalized every year. Some will be permanently disabled, and some will never be able to carry a child again. Yet we will never know the full extent of the problem, because there are many women and girls who cannot get access to medical care.

DR Congo 2019 © Davide Scalenghe/MSF

Unsafe abortion is a medical crisis

In 2022, MSF staff treated over 25,000 women and girls for abortion-related concerns and complications, many of which resulted from unsafe attempts to terminate pregnancy. 

The woman or girl may have consulted an unskilled provider, or attempted the abortion herself. The history of unsafe abortion is marked by dangerous abortion methods—including the use of sharp sticks inserted through the vagina and cervix into the uterus; ingestion of toxic substances such as bleach; herbal preparations inserted into the vagina; infliction of trauma, such as hitting the abdomen or falling. Many of these unsafe abortion methods are not even effective in terminating the pregnancy, but can leave lasting damage.

In the operating theater, examining many of these women, I found trauma marks on the cervix, caused by objects such as sticks. Dr. Claire Fotheringham, MSF women’s health advisor, on her assignment in West Africa

For women who use these unsafe methods, the life-threatening consequences include severe hemorrhage, sepsis (severe general infection), poisoning, uterine perforation, or damage to other internal organs. A woman may require urgent hospital care for a blood transfusion, major reparative surgery, or a hysterectomy—the complete, and irreversible, removal of the uterus.

Some women are able to access somewhat safer methods like medication on the black market, but they may still suffer complications due to poor drug quality, incorrect dosing, inadequate information, or a combination of these factors.

In the worst-case scenario, the woman being treated may have been refused a safe abortion, only to reappear with life-threatening injuries due to an unsafe one. In the  Democratic Republic of Congo  (DRC), where abortion used to be extremely restricted legally, emergency department doctor Jean-Paul remains shaken by his direct experience of encountering a girl seeking an abortion. Denied care in the MSF hospital he was working in, she returned in a coma, and died not long afterward.

Five takeaways from MSF’s study on unsafe abortions

How moral judgment and shame impact dangerous abortions

A woman may hope to be pregnant one day in the future, but not necessarily right now. MSF’s experience in countries such as Colombia, Greece, Mozambique, and South Africa, to name just a few, has confirmed the diversity of woman and girls facing an unwanted pregnancy: our patients are married and unmarried, women with children as well as girls attending school, women from urban centers and rural villages alike.

Some of these women and girls used contraception that failed or ran out due to interrupted supply. Some became pregnant due to sexual violence or coercion. Others faced financial and emotional hardship, with and without partners or family support. Some were caught up in a humanitarian crisis or forced from their homes, struggling just to survive.

There can be as much shame and stigma surrounding the reasons behind an unwanted pregnancy as the concept of abortion itself. This means that many women and girls are left to face difficult questions alone. Where can I go for help? What are my options? What will it cost? Will it be painful? What if I can never have children again? What will this mean for me and my family if people find out?

Most women have already thought about their options and made the decision before seeking care. Some women may ask for more information before deciding whether to have an abortion. Our role as medical providers is to listen and provide the appropriate level of support and information, respecting her decision without judging or influencing her.

Consultation with a trained professional also ensures that the woman understands the risks and benefits of an abortion, knows what she will experience during the process, and has the opportunity to ask questions.

Legal limitations to abortion

The fact that abortion is still criminalized in most countries remains a concern. The evidence is clear that the number of abortions changes little when there are legal restrictions. Instead, where abortion is most restricted, it is more likely to be unsafe. Where abortion is legal and safe services are available, deaths and disability from abortion are greatly reduced.

Prompted by the evidence, some countries have reformed their laws.

Legislation in DRC changed in April 2018. Since then, all medical facilities have the obligation to provide termination of pregnancy for women who have been victims of rape or sexual abuse, or whose physical or mental health is at risk.

Mozambique revised its stance four years earlier, in 2014, allowing for cost-free abortion for all women in the first trimester, and up to 24 weeks under special circumstances in approved facilities by qualified practitioners.

Barriers in the health care system can lead to unsafe abortion

Liberalization and decriminalization of abortion are important steps, but they do not guarantee the availability of safe abortion care. Many health systems respond slowly, and inconsistently, to change.

In Mozambique , for example, clinical standards for safe abortion were only defined in 2017. Institutional opposition, resistance from health workers, and knowledge gaps on the part of decision-makers have all hindered the wider implementation of safe abortion care in the country, and many women still do not know how to access services.

In Colombia , significant decriminalization of abortion was achieved 12 years ago. But in the port cities of Buenaventura and Tumaco, MSF found general ignorance about the current scope of safe abortion care. Health care workers who should have been prepared to undertake this type of care were not even aware that it was part of their duty.

My head was exploding, I thought, 'My God, what am I going to do?' MSF patient in Colombia on the difficult decisions she faced with an unwanted pregnancy

For a woman or girl with an unwanted pregnancy, it can be hard to overcome the sometimes strong resistance from health care providers, which may even extend to the denial of care.

In Athens, where MSF supports migrants, asylum-seekers, and refugees to access safe abortion care in the public health system, women join a waiting list more than four weeks long just to have their first appointment. More appointments with more health professionals, especially doctors, follow. Some patients face additional obstacles, because they don’t have their social security identification with them, or attend an appointment without a translator.

In Greece , the legal limit for abortion is 12 weeks, so women must race against the clock to navigate the many hurdles in order to end their pregnancy within that period.

To prevent unsafe abortions, simplify abortion access

Termination of pregnancy is a safe and effective medical act, usually managed with tablets (medication abortion) or a minor intervention under local anesthesia (manual vacuum aspiration, or MVA). Both of these abortion methods are less risky than an injection of penicillin.

Medication abortion involves two drugs, mifepristone and misoprostol, and a total of only five pills. It is often the preferred method for women, as it is less invasive and can be started as an outpatient and completed in the privacy of one’s own home. 

Doctors are not necessary to provide these services; midwives and nurses can provide both of these abortion methods in hospitals and health centers alike, as long as they have the skills.

The backstreet clinics weren't one of my options because people end up losing their lives. I went to Puken health center for help. Everyone was friendly. They told us the whole procedure, every step. Patricia, MSF patient

Even so, in places where health services are stretched, providers can benefit greatly from additional support—further training, institutional backing, mentoring, and guidance. In Rustenburg, South Africa , this is an important component of nurse Kgaladi Mphahlele’s work as a Choice of Termination of Pregnancy Manager on behalf of MSF. The district health service is committed to providing safe abortion care, but staff can be unsure of correct methods and protocol.

Some staff also need moral support in the face of judgment and stigma from colleagues in the workplace. Even knowing the importance of safe abortion care, many health providers—including MSF—must confront their personal attitudes toward providing this care. Peer support is important.

The woman has the freedom to decide whether she wants to be a mother at the moment. Ana Paula de Sousa, MSF midwife in Mozambique, on providing access to safe abortion care

Ensuring abortion safety

Safe abortion care is a package of essential health services: management of post-abortion complications, safe termination of pregnancy, and provision of contraceptives. These services need to be timely, reliable, confidential, skilled, and compassionate. They must be provided by people who have been properly trained.

Contraception and safe abortion care go hand in hand in the strategy to reduce unwanted pregnancies, unsafe abortions, and maternal deaths. Increasing access to modern contraception is an essential component to reducing unintended or unwanted pregnancies, and the abortions or unplanned births that often follow. However, contraception alone is not sufficient as a solution.

Safe abortion care at MSF

MSF is working with its staff, with local communities, health departments and ministries, and other non-governmental health care providers to improve access to contraceptives, to post-abortion care and to the safe termination of pregnancy for women and girls lacking access to health care or caught in a humanitarian crisis.

Unwanted pregnancy and unsafe abortion have serious medical impacts on women and girls in many of the low-resource settings and conflict-affected countries where MSF works. The consequences of unsafe abortion are also felt by these women’s families and friends, caregivers—including MSF staff—and their wider community. As a medical and humanitarian organization, MSF remains committed to providing safe abortion care to reduce this avoidable—and often overlooked—cause of suffering.

A woman deserves health care that responds to her medical needs, including access to safe abortion care

More news and stories

Story Sep 06, 2023

Story Sep 28, 2022

Q&A: How MSF provides abortion care now

Story Sep 28, 2021

My abortion story

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