A multi-country research study led by the World Health Organization (WHO), the United Nations Special Research Programme HRP*, and partners in 17 countries is shedding light on the severity and clinical management of abortion-related complications.
Published in The BMJ Global Health, the facility-based study across 11 sub-Saharan African countries and 6 Latin American and Caribbean countries also explores women's experience of post-abortion care.
Researchers collected data from more than 20,000 women presenting at over 200 participating health facilities with an abortion-related complication. Their signs and symptoms were classified into one of five categories, based on severity: deaths, near miss, potentially life-threatening complications, moderate complications and mild complications.
The majority of women in the study suffered a mild to moderate complication. However, twice as many women in the African sites than in the Latin America and Caribbean sites had a potentially life-threating complication, or nearly died.
Social and economic factors are a major risk factor for mortality and morbidity
Abortion remains a stigmatized issue. This can hinder access to safe abortion, particularly for women living in poverty or places where access to effective contraception and safe abortion is limited or unavailable.
Women in the study who were single, pregnant for 13 weeks or more, or presenting with an incomplete abortion were significantly more likely to suffer a severe outcome.
"Abortion represents a field where inequality is such a big issue," explained Mariana Romero, National Scientific and Technical Research Council (CONICET) and Center for the Study of State and Society (CEDES), who led the study in Argentina. "A woman with material resources has different opportunities to access safe and informed care than a woman with less economic advantage."
Listening to women's experiences
High-quality abortion care is about much more than clinical management. Respect and dignity are integral.
By asking women about their personal experience of post-abortion care, the study shows how much more work is needed to ensure effective communication and emotional support. This includes efforts to reduce anxiety during examinations, answering women's questions and giving explanations at the time of care.
"As healthcare providers, if we are talking about care, we have to include not only the physical wellbeing of a person but also autonomy and empowerment. When a woman puts herself in the hands of the health system we need to build trust, confidence, and ensure this person feels comfortable coming back to us," continued Mariana Romero.
Learning from data to improve access to safe abortion and contraceptive counselling
In both regions, the study found that dilation and curettage was still used in the management of abortion-related complications – despite longstanding global efforts to replace this method with safer uterine evacuation methods, as recommended by WHO.
"The study shows us we still have a long way to go to move away from the older methods such as curettage and provide better care with safer medical methods," said Zahida Qureshi, Associate Professor at the University of Nairobi, who led the study in Kenya and was the regional coordinator for Anglophone countries in Africa.
"These data will help pick up things we need to improve at each level: from a good referral system that can direct women to facilities with the right supplies, equipment and availability of essential staff, to contraceptive counselling to prevent a pregnancy women do not desire to have, and access to quality of care at every stage."
Implementing WHO recommendations for safe abortion
Safe abortion protects women's and girls' health and human rights. However, unsafe abortions persist, despite scientific advances that enable the provision of safe abortion, such as medical abortion using misoprostol in accordance with WHO recommendations.
WHO estimates that nearly half of all abortions in Africa happen in the least safe circumstances, using dangerous, invasive methods which carry the greatest risk of severe complications and death. In Latin America, the proportion is around 1 in 5.
The multi-country study highlights the need for WHO recommendations to be implemented within countries, both to ensure access to safe abortion and to better manage complications when they occur.
"If you want to answer complex questions, you have to collaborate as a team," explained Dr Guillermo Carroli, Centro Rosarino de Estudios Perinatales (CREP), who coordinated the research across Latin America.
"The strong design of this study gives us a real picture of abortion safety in the region, with an approach that is grounded in respect for human rights. Some of the news is good, some of it is not so good – but it provides us with concrete data, and a platform to work from together."
Later this year, WHO will publish an updated and consolidated guideline that brings together clinical, health system and policy recommendations on abortion care.
Additional materials:
Understanding abortion-related complications in health facilities: results from WHO multi-country survey on abortion across 11 sub-Saharan African countries: BMJ Global Health read here.
Abortion-related morbidity in six Latin American and Caribbean countries: findings of the WHO/HRP multi-country survey on abortion: BMJ Global Health read here.
What's needed to improve safety and quality of abortion care: reflections from WHO/HRP Multi-Country Study on Abortion across the sub-Saharan Africa and Latin America and Caribbean regions: BMJ Global Health read here.
Learn more about WHO multi-country surveys here.
