PUBLIC HEALTH ASPECTS OF PUBLIC HEALTH ASPECTS OF ABORTION:ABORTION:

AN OVERVIEWAN OVERVIEW

ByBy

Prof F. E. OkonofuaProf F. E. OkonofuaProvostProvost

College of Medical SciencesCollege of Medical SciencesUniversity of BeninUniversity of Benin

Abortion is the loss of pregnancy Abortion is the loss of pregnancy before it has reached stabilitybefore it has reached stability

Two types:Two types: Spontaneous Spontaneous Induced Induced

Estimates of AbortionEstimates of Abortion

1.1. Spontaneous Abortion – Estimates are Spontaneous Abortion – Estimates are unknown, because many are non-clinical unknown, because many are non-clinical abortionsabortions

2.2. Induced AbortionInduced AbortionDeveloped Countries Developed Countries -- 500,000500,000Developing Countries Developing Countries -- 18,400,00018,400,000Total (World)Total (World) -- 19 million 19 million Africa Africa -- 4.2 million4.2 millionNigeria Nigeria -- 610,000610,000

Impact of induced Abortion Impact of induced Abortion Number of Number of % of all % of all

maternal deaths maternal deaths maternal maternal deathsdeaths

From AbortionFrom Abortion

World World 67,90067,900 1313

Developed countries Developed countries 300300 1414

Developing Countries Developing Countries 67,50067,500 1313

Africa Africa 29,80029,800 1212

Nigeria Nigeria *20,000*20,00040*40*

Clinical Aspects of Clinical Aspects of Spontaneous AbortionSpontaneous Abortion

Spontaneous AbortionSpontaneous Abortion

Threatened AbortionThreatened Abortion Inevitable AbortionInevitable Abortion (including belighted ovum and (including belighted ovum and

missed missed abortion)abortion)

Incomplete AbortionIncomplete Abortion Complete Complete

Abortion Abortion

Threatened AbortionThreatened Abortion

Mild to moderate vaginal bleeding Mild to moderate vaginal bleeding Uneffaced and undilated cervixUneffaced and undilated cervix No abdominal pain No abdominal pain Fetus often viable Fetus often viable Conservative management Conservative management

Inevitable Abortion Inevitable Abortion

1.1. Blighted ovumBlighted ovum

2.2. Severe effacement and dilatation of Severe effacement and dilatation of the cervix, with or without passage the cervix, with or without passage of products of conception of products of conception

3.3. Death and retention of the fetus Death and retention of the fetus between 12 and 28 weeks (missed between 12 and 28 weeks (missed abortion)abortion)

Treatment of Inevitable Treatment of Inevitable Abortion Abortion

1.1. D&C versus MVAD&C versus MVA

2.2. MisoprostolMisoprostol

-- all stages, including all stages, including blighted ovumblighted ovum

Aetiology of Recurrent Aetiology of Recurrent AbortionAbortion

1.1. Cervical Incompetence Cervical Incompetence 2.2. Maternal illnesses – hypo or Maternal illnesses – hypo or

hyperthyroidism diabetes mellitus, hyperthyroidism diabetes mellitus, cardiovascular diseases cardiovascular diseases

3.3. Materno-fetal infections (toxoplasmosis, Materno-fetal infections (toxoplasmosis, Listeria monocytogene, rubella, Listeria monocytogene, rubella, cytomegalovirus, herpes simplex virus, cytomegalovirus, herpes simplex virus, brucella, Chlamydia, ureaplasma brucella, Chlamydia, ureaplasma urealyticum, T-strain mycoplasma)urealyticum, T-strain mycoplasma)

4.4. Endocrine factors – polycystic ovarian Endocrine factors – polycystic ovarian disease, luteal phase defect disease, luteal phase defect

5.5. Chromosomal anomalies Chromosomal anomalies 6.6. Immunological incompatibilityImmunological incompatibility

Investigation of Recurrent Investigation of Recurrent AbortionAbortion

1.1. Detailed History and physical examination Detailed History and physical examination 2.2. Hormone AssayHormone Assay3.3. Thyroid, renal & liver function tests Thyroid, renal & liver function tests 4.4. Glucose tolerance testsGlucose tolerance tests5.5. HSGHSG6.6. Ultrasound scan Ultrasound scan 7.7. SLE Lupus anti-coagulant test SLE Lupus anti-coagulant test 8.8. Anti-cardiolipin antibodies Anti-cardiolipin antibodies 9.9. Anti-nuclear factor Anti-nuclear factor 10.10. Anti-thyroid antibodies Anti-thyroid antibodies 11.11. Blood grouping Blood grouping 12.12. HLA typing in both partners HLA typing in both partners

Treatment of Recurrent Treatment of Recurrent Abortion Abortion

Treatment of underlying medical Treatment of underlying medical conditions conditions

Progesterone vaginal pressaries Progesterone vaginal pressaries MyomectomyMyomectomy Cervical cerclageCervical cerclage

-- Lash & Lash procedureLash & Lash procedure-- Shirodkar’s techniqueShirodkar’s technique-- MacDonald's techniqueMacDonald's technique

Induced Abortion Induced Abortion

Induced Abortion is done in all societies Induced Abortion is done in all societies and in all culturesand in all cultures

The issues is whether it is safe or unsafe The issues is whether it is safe or unsafe Induced abortion tends to be safe in Induced abortion tends to be safe in

countries where abortion is legal and countries where abortion is legal and unsafe in countries where abortion is unsafe in countries where abortion is restrictive and legalrestrictive and legal

Abortion tends to be safe in developed Abortion tends to be safe in developed countries and unsafe in developing countries and unsafe in developing countries countries

Patterns of Abortion Law in Patterns of Abortion Law in Africa Africa CountriesCountries

No of CountriesNo of Countries1.1. Abortion to save life of Abortion to save life of pregnant woman only pregnant woman only 24242.2. Abortion to preserve the life or health of a woman Abortion to preserve the life or health of a woman 9 9

3.3. To save her life and in cases of rape To save her life and in cases of rape 224.4. To preserve her life or health in cases of To preserve her life or health in cases of

contraceptive failure contraceptive failure 115.5. In cases of pregnancy resulting from rape and In cases of pregnancy resulting from rape and

incest – and fetal defect & to preserve her life & health incest – and fetal defect & to preserve her life & health 99

6.6. Additional indication of socioeconomic hardshipAdditional indication of socioeconomic hardship(Zambia)(Zambia) 11

7.7. Additional indication of a woman who is too young orAdditional indication of a woman who is too young or mentally unable to care for a child (Ethiopia) mentally unable to care for a child (Ethiopia) 1188 On request (Cape Verde, South Africa & Tunisia) On request (Cape Verde, South Africa & Tunisia) 33

TOTALTOTAL 5353

Why Women have Unwanted Why Women have Unwanted Pregnancy and Seek Abortion Pregnancy and Seek Abortion

They are too young or want postpone child They are too young or want postpone child bearing bearing

They want no more children They want no more children They cannot afford to raise a child They cannot afford to raise a child They are unmarried or still in school They are unmarried or still in school Their partners does not want the pregnancy Their partners does not want the pregnancy

or there is a problem with relationship or there is a problem with relationship They become pregnant due to rape or incestThey become pregnant due to rape or incest

Determinants of unwanted Determinants of unwanted Pregnancy and Unsafe AbortionPregnancy and Unsafe Abortion Young maternal age Young maternal age The role of women education The role of women education Pattern of contraceptive use Pattern of contraceptive use Religion Religion Abortion laws Abortion laws Provider attitude and training Provider attitude and training Use of outdated abortion methods and Use of outdated abortion methods and

technology technology Economic and geographic inequality Economic and geographic inequality

Complications of Induced Complications of Induced Abortion Abortion

Immediate Immediate

-- Occurring during or within Occurring during or within 48 48 hours hours

LateLate

-- Occurring later, especially Occurring later, especially after 48 after 48 hours hours

Early Complications of Induced Early Complications of Induced AbortionAbortion

Haemorrhage Haemorrhage Damage to adjacent organs – Damage to adjacent organs –

perforated uterus perforated uterus Sepsis (Septic abortion)Sepsis (Septic abortion)- Gram negative septicaemia Gram negative septicaemia

Treatment of Early Treatment of Early Complications of Induced Complications of Induced

Abortion Abortion 1.1. Intravenous infusion and/or blood Intravenous infusion and/or blood

transfusion transfusion

2.2. Blood spectrum antibiotics Blood spectrum antibiotics

3.3. Evacuation of retained products of Evacuation of retained products of conception (MVA)conception (MVA)

4.4. Laparotomy Laparotomy

Late complications of induced Late complications of induced Abortion Abortion

1.1. Chronic pelvic inflammatory diseaseChronic pelvic inflammatory disease

2.2. Ectopic pregnancy Ectopic pregnancy

3.3. Cervical Incompetence Cervical Incompetence

4.4. Asherman syndrome Asherman syndrome

Regimen for Safe Practice of Regimen for Safe Practice of Abortion Abortion

AA 11stst seven weeks seven weeks Mifepristone – misoprostol Mifepristone – misoprostol Misoprosotol alone Misoprosotol alone MVAMVA D & CD & C

B B 8 – 14 weeks 8 – 14 weeks Misoprostol – MVA Misoprostol – MVA Misoprostol – D & CMisoprostol – D & C

C C After 14 weeks After 14 weeks Mifepristone – misoprostol Mifepristone – misoprostol Repeated doses of misoprostol Repeated doses of misoprostol

Different Perspectives of Different Perspectives of Abortion Abortion

Abortion Abortion -- a public health issue a public health issue Abortion Abortion -- a gender issue a gender issue Abortion Abortion -- a rights issue a rights issue

-- right to life right to life -- right to health, reproductive right to health, reproductive

health and family planning health and family planning -- right to be free from right to be free from

discrimination discrimination -- right to liberty & security of right to liberty & security of

persons persons -- right to scientific progress right to scientific progress

AbortionAbortion - - a social and economic justice a social and economic justice issue issue

Prevention of Unsafe Prevention of Unsafe Abortion Abortion

AA Primary Prevention Primary Prevention -- sexuality education sexuality education -- promotion of contraception promotion of contraception

BB Secondary Prevention Secondary Prevention - provision of counseling to women with - provision of counseling to women with unwanted pregnancies unwanted pregnancies -- Liberation of abortion laws Liberation of abortion laws -- Increasing women’s access to safe Increasing women’s access to safe abortion abortion services services

CC Tertiary Prevention Tertiary Prevention -- Post abortion Care (PAC) at all levels Post abortion Care (PAC) at all levels -- In-services and pre-service training of In-services and pre-service training of providers providers -- Decentralization of PAC Decentralization of PAC

Thank youThank you