Unwanted Pregnancy, Unsafe Abortion, Post-abortion Care and Abortion Laws

BY

Prof AS Anzaku

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OUTLINE

• Introduction
• Unwanted pregnancy;

* Definition of terms & prevalence rates

* Predisposing factors

* Risks & consequences

* Management strategies

* Prevention

• Unsafe abortion, complications and management
• Post-abortion care
• Abortion Laws in Nigeria
• Conclusion

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Introduction

Every year worldwide;

• 205 million pregnancies occur
• 40% of them are unplanned (82 million)
• Unplanned pregnancy may be unwanted and so increases a woman’s risk of death;

* Increased exposure to pregnancy complications

* Complications related to unsafe abortion

• 40 million induced abortions occur each year
• 20 million of these are unsafe abortions (50%)

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Introduction cont;

• 67,000 women die from unsafe abortion annually
• This constitutes about 13% of all pregnancy-related deaths
• Majority of deaths from unsafe abortion are in Asia and sub-Saharan Africa
• The main cause of unsafe abortion is unmet need for family planning
• 137 million women have unmet need for FP

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Definitions

• Unintended pregnancy: Is a pregnancy that is mistimed, unplanned or unwanted at the time of conception
• Unplanned Pregnancy: Pregnancy that occurs without a conscious effort for one
• Unwanted pregnancy: Pregnancy whose existence or continuation is undesired or unacceptable
• Removal of the pre-fix “Un” depicts opposite meanings of above terms

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• NOTE: Feelings towards pregnancy can change tremendously during the course of the pregnancy;
• Change of circumstance may lead to a continue pregnancy been unwanted

*Hence, there may be a desire to terminate an initial intended pregnancy

• An initially unwanted pregnancy might be welcomed later

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Prevalence rates;

• 39.6% of pregnant women in BHUTH had unplanned pregnancy - Anzaku et al (J Basic Clin Reprod Sci, 2013)
• 28% of women aged 15-49 have had unwanted pregnancies – Bankole et al (International Family Planning Perspectives, 2006)
• 7% of Births in Nigeria were unplanned (NDHS 2008)
• 4% of Births were unwanted (NDHS 2008)

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Unwanted pregnancy cont;

• Categories of women prone to unwanted pregnancies;

- Unmarried women – singles, divorced

- Married women

- Teenagers

- Multiparous women

- Widows

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Predisposing factors to unwanted pregnancy

• Low levels of contraceptive use – low accessibility
• Inconsistent/incorrect use of contraceptives
• Contraceptive failure
• Desire for smaller family size
• Urbanization & women’s involvement in paid labor
• Unsolicited sex – Rape etc

NOTE:

Two major options available to women with unwanted pregnancies

a) Do nothing – continue with the pregnancy

b) Termination of pregnancy (TOP)

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Risks and consequences of continuing with Unwanted Pregnancy

MEDICAL

• Bleeding in pregnancy
• Severe anemia
• Prolonged, difficult & obstructed labor
• Stillbirths
• Low birth weight
• Maternal/Infant deaths

SOCIO-ECONOMIC

• Termination of education
• Poor job prospects
• Loss of self-esteem
• Broken relationships (with partners, friends and parents)

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Risks and consequences of TOP

• Sepsis
• Haemorrhage
• Organ injuries (e.g. bowel, VVF, RVF)
• Long term complications
• Infertility
• Ectopic pregnancy
• Chronic pelvic pain
• Cervical incompetence
• Mortality

NOTE:

- 80% of complications involve adolescents

- 20,000 die annually

- 11-40% Maternal Mortality

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Management of unwanted pregnancy

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• Counseling:
• Helping to make informed choice/decision

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• Support:

- To implement her choice/decision

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COUNSELING

• Depends on the intention of the woman disclosed to the health provider

- To abort or continue with pregnancy

• Relevant things to consider during counseling:

- Age of patient & consent issues

- Soundness of mind

- Partner factor

- Parental issues

- Confidentiality

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Counseling cont;

If to abort:

- How, who, where, when ?

- What immediate or remote implications?

• Note provision of the law

- Termination of pregnancy is a criminal offence for both the client and the practitioner, except it is done on grounds of ‘danger to a woman’s life’

- Criminal Code of the Southern States -

sections: 228, 229, 230 & 297

- Penal Code of the Northern States - sections: 232 & 234

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Counseling Cont;

If to preserve and continue the pregnancy;

• Discuss and counsel about issues related to;

- Safe management of pregnancy and delivery

- Handling reasons for disapproval of the pregnancy later

- Her management after delivery

- Management of the newborn

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PROVIDERS’ DILEMMA IN SUPPORTING PATIENT’S CHOICE

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PERSONAL BELIEFS & VALUES

Pro-choice or Anti-choice

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PROFESSIONAL ETHICS

Autonomy,

Beneficence,

Non-malficence

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LEGAL PROVISIONS

Restriction of abortion to save mother’s life

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SUPPORT FOR PATIENT’s CHOICE

If patient’s choice is TOP;

• Reinforce counseling on risks & implications
• Provide service if available
• Provide useful information that:
• Protects against exposure to quacks
• Lead to safe service providers
• Be available to give further support when necessary
• Especially prevention of recurrence - contraception

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If patient’s choice is to continue with the pregnancy;

• Ensure early antenatal care
• ANC screenings, assessments & interventions
• Provide financial/social support
• Birth preparedness and complication readiness
• Supervised delivery
• Postpartum care/support – lactation, contraception

- Social support If unmarried, address stigma & discrimination of single-motherhood

- Economic support

- Psychological & spiritual support

-Neonate- Immunization, nutrition

*Care -Biologic mother, Relative, adoption, fostering

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Prevention of unwanted pregnancies

YOUNG PEOPLE

• Need to acquire accurate & comprehensive knowledge on sexuality & RH
• Adopt principles of self-control and discipline
• Make good friends and have positive peers
• Keep busy and be positive

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PARENTS

• Parents are primary sexuality educators of their children: what they say or do
• Parents be well informed
• Serve as models in their own relationships
• Train children to have self-esteem
• Train them to build & keep responsible relationships

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Prevention cont;

HEALTH CARE PROVIDERS

• Develop health care protocols that meet needs of young adults
• Be sensitive to concerns of women & community
• Be non-judgemental & confidential
• Remove unnecessary barriers on access to contraceptives, e.g. marital status

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POLICY MAKERS

• Improved access to sexual & RH information & services
• Prohibit abuse of women & young people
• Support improved education & employment opportunities for females & young people
• Law reforms

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The circle of unwanted pregnancy

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Illegal abortion

Legal abortion

Contraceptive non-use

Birth and adoption

Contraceptive failure

Restricted access

Free access

Contraceptive use

Emergency care for abortion complications

Pregnancy not wanted

Unplanned or �unwanted pregnancy

UNSAFE ABORTION

• Define as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both (WHO)
• Globally, an estimated 205 million women become pregnant annually
• One in five of these women resort to abortion
• Out of about 40 million abortions performed annually, 20 million are estimated to be unsafe

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• 95% of unsafe abortion occurs in developing countries
• Globally, about 68,000 women die each year due to unsafe abortion
• 5.3 million suffer temporary or permanent disability
• For every woman who dies, many more are left wounded, some with life-long consequences, including infertility, chronic pelvic pain and genital trauma
• Unsafe abortion is a significant yet preventable cause of maternal mortality

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• Nigerian situation; Unsafe abortion
• 25 /1000 women of reproductive age
• 610,000 abortions occur annually
• 40% of maternal deaths
• Common among unmarried adolescents
• More than 50% of severe complications occurs among adolescents
• Why do women abort pregnancy?
• To stop or postpone childbearing
• Socioeconomic reasons – poverty, education delay
• Relationship problems – partner, parents
• Young age or health reasons
• Stigma of single parenthood
• Pregnancy resulting from rape or incest

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Techniques of unsafe abortion

• Insertion of foreign objects into the genital tract - sticks, roots, wires, knitting needles, hangers
• Abdominal Massage
• Repeated blows to the abdomen
• Herbal medications given by vaginal pessary or by mouth, potassium permanganate tablets
• Drugs & harmful chemicals like quinine, potash, lime and heavy alcohol
• Misoprostol tablets

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Perpetrators of Unsafe Abortion

• Unskilled health personnel
• Untrained doctors
• Untrained nurses/midwives
• Paramedics
• Pharmacist
• Ward attendants
• Physiotherapist
• Other hospital workers
• Traditional birth attendants
• Native doctors
• Others

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Clinical features of unsafe abortion

• Young & often single
• Amenorrhoea
• Abdominal pain, distension, anorexia, vomiting
• Vaginal bleeding
• Offensive vaginal discharge
• Fever
• Pallor, Jaundice, dehydration, shock
• Peritonitis, hepatomegaly
• Genital tract laceration
• Bleeding from orifices
• Renal failure

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Complications

• Early complications;
• Haemorrhage
• Infections – genital sepsis & septicaemia, HIV, tetanus
• Genital tract trauma – vaginal and cervical lacerations
• Vesico-vaginal fistula, RVF
• Visceral injuries – uterine perforation, intestinal injuries
• Shock – septic or hypovolaemic
• Acute renal failure
• Coagulopathy

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Complications of unsafe abortion cont;

• A 19 year old girl with necrotic intestines protruding from the vagina, following D&C for induced Abortion

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• Late complications;
• Chronic pelvic pain
• Dyspareunia
• Chronic PID
• Asherman’s syndrome
• Infertility
• Recurrent abortion – cervical incompetence
• Ectopic pregnancy
• Intestinal obstruction - adhesions
• Gynaetresia

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19-year old with acquired gynetresia following TOP with herbs due to chemical vaginitis - Anzaku et al

USS – haematometria & haematocolpos

Vaginal mould insitu after vaginoplasty

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Investigations

• Haematocrit
• Grouping & cross-matching
• Full blood count
• Blood culture
• Urea & electrolytes, Cr
• Pelvic ultrasound scan
• Abdominal & chest x-ray
• Microscopy, culture & sensitivity
• Coagulation screening

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Treatment of complications

• Haemorrhage and Incomplete abortion
• Resuscitation
• Prompt empirical antibiotic therapy
• Correct anaemia
• Prompt uterine evacuation of incomplete abortion and control bleeding
• Manual vacuum aspiration
• Dilatation & Curettage
• Misoprostol or oxytocics

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• Infections;
• Parenteral antibiotics – cover gram positive, negative organisms and anaerobes
• Laparotomy – pelvic abscess
• Tetanus - requires the administration of tetanus immune globulin,

- primary immunization

- Supportive therapy as the disease runs its course

• ARF - Dialysis

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Prevention of unsafe abortion

• Education, employment and empowerment of the girl child
• Provision of reproductive health information & services
• Sexuality education for all age groups
• Promotion of all forms of family planning
• Formulation of national policy on adolescent reproductive health
• Information and counselling to women experiencing unwanted pregnancies
• Providing support for unwanted pregnancies & alternatives to abortion –BHUTH Prolife Unit
• Reform restrictive abortion laws & policies

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POST ABORTION CARE (PAC)

• Post abortion care is an approach for reducing injuries and deaths from incomplete and unsafe abortions and their resulting complications
• Improves women's sexual and reproductive health and lives
• Signs needing immediate intervention
• Fever, chills, fainting, vomiting
• Swollen, tender abdomen
• Offensive vaginal discharge
• Cramping, bleeding more than normal menses
• Delay in resumption of menstruation (more than eight weeks)

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Essential elements of PAC

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• Community and service provider partnerships
• Prevent unwanted pregnancies and unsafe abortion – availability of contraceptives
• Mobilize resources to help women receive appropriate and timely care for complications of abortion
• Ensure that health services reflect and meet community expectations and needs
• Participation by community members in decisions about availability, accessibility and cost of services
• Counseling
• Identify and respond to women's emotional, physical, health and spiritual needs etc

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• Treatment of complications
• Treat incomplete and unsafe abortion and potentially life-threatening complications
• Family planning and contraceptive services
• Help women practice birth spacing or prevent an unwanted pregnancy
• Reproductive and other health services
• Preferably provide on-site, or via referrals to other accessible facilities in provider's network e.g STIs, Pap smear, GBV

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Nigeria’s Abortion Laws

Abortion Laws in Nigeria

• Two different laws govern abortion in Nigeria
• - Criminal code (1916)- in Southern Nigeria
• - Penal code (1959)- in Northern Nigeria

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Criminal Code

• Permits an abortion to be legally performed only to save the life of the mother
• Section 297 provides that a person is not criminally responsible for performing in good faith and with reasonable care and skill a surgical operation upon an unborn child for the preservation of the mother’s life

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• Any person who with intent to procure the miscarriage of a woman whether she is or is not with a child, unlawfully administers to her any poison or other noxious thing, or uses force of any kind, any other means whatever is guilty of felony and is liable to imprisonment for 14 years (sect. 228)
• A woman who undertakes the same act with respect to herself or consent to it is subject to 7 years imprisonment (Sect. 229)
• Any person who supplies anything that is intended to be unlawfully used to procure a miscarriage is subject to 3 years imprisonment (Sect. 230)

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Penal Code

• An abortion may be legally performed only to save the life of the pregnant woman
• A person who voluntarily causes a woman with child to miscarry is subject to 14 years imprisonment and/or payment of fine (sect. 232)
• A woman who causes her own miscarriage is subject to the same penalty
• Harsher penalties are applied if the woman dies as a result of the miscarriage

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• “ Any person who, with intent to cause the miscarriage of a woman, regardless of whether she is pregnant or not, does any act that causes her death is liable to imprisonment for fourteen years” (Section 233)

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Summary on Nigeria’s Abortion Laws

• The legal indications for abortion in Nigeria is quite restrictive, thus making unsafe abortion a silent and persistent killer of women
• Access to abortion services is particularly important for women and girls who are victims of sexual Violence, rape and incest
• There is a need for a review of our restrictive abortion laws due to the Human Rights implications of unsafe Abortion
• Lack of political will on the part of Government will only continue to send our women to their early graves in large numbers

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CONCLUSION

• Unwanted pregnancy is better prevented
• Unsafe abortion is a major public health problem in Africa and is responsible for the deaths and disabilities of thousands of women each year
• Prompt management of complications are essential in reducing morbidity and mortality
• Education, employment and empowerment of women should be strongly adopted to prevent unsafe abortion

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THANK YOU

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