How risky are second trimester clandestine abortions in Cameroon: a retrospective descriptive study

Comparison of the effectiveness and safety of treatment of incomplete second trimester abortion with misoprostol provided by midwives and physicians: a randomised, controlled, equivalence trial in Uganda

Background

To address the knowledge gaps in the provision of post-abortion care by midwives for women in the second trimester, we investigated the effectiveness and safety of treatment for incomplete second trimester abortion with misoprostol, comparing care provision by midwives with that provided by physicians in Uganda.

Methods

Our multicentre, randomised, controlled, equivalence trial undertaken in 14 health facilities in Uganda recruited women with incomplete abortion of uterine size 13–18 weeks. We randomly assigned (1:1) women to clinical assessment and treatment by either midwife or physician. The randomisation sequence was computer generated, in blocks of four to 12, and stratified for study site. Participants received sublingual misoprostol (400 μg once every 3 h for up to five doses). The study was not concealed from the health-care providers and study participants. Primary outcome was complete abortion within 24 h that did not require surgical evacuation. Analysis was per-protocol and intention to treat; the intention-to-treat population consisted of women who were randomised, received at least one dose of misoprostol, and reported primary outcome data, and the per-protocol population excluded women with unexplained discontinuation of treatment. We used generalised mixed-effects models to obtain the risk difference. The predefined equivalence range was –5% to 5%. The trial was registered at ClinicalTrials.gov, NCT03622073.

Findings

Between Aug 14, 2018, and Nov 16, 2021, 1191 eligible women were randomly assigned to each group (593 women to the midwife group and 598 to the physician group). 1164 women were included in the per-protocol analysis, and 530 (92%) of 577 women in the midwife group and 553 (94%) of 587 women in the physician group had a complete abortion within 24 h. The model-based risk difference for the midwife versus physician group was –2·3% (95% CI –4·4 to –0·3), and within our predefined equivalence range (–5% to 5%). Two women in the midwife group received blood transfusion.

Interpretation

Clinical assessment and treatment of second trimester incomplete abortion with misoprostol provided by midwives was equally effective and safe as when provided by physicians. In low-income settings, inclusion of midwives in the medical management of uncomplicated second trimester incomplete abortion has potential to increase women's access to safe post-abortion care.

Funding

Swedish Research Council and THRiVE-2.

Unmet Need for Family Planning and Experience of Unintended Pregnancy Among Female Sex Workers in Urban Cameroon: Results From a National Cross-Sectional Study

Female sex workers (FSWs) in Cameroon have unmet need for effective contraception, and experience of unintended pregnancy and pregnancy termination is common. Reducing barriers to accessing high-quality, voluntary family planning services in FSW-focused community services is a key strategy to promote client-centered care, promote informed choice, reduce unintended pregnancies, and improve quality of life for FSWs.

Background:

Female sex workers (FSWs) in Cameroon commonly have unmet need for contraception posing a high risk of unintended pregnancy. Unintended pregnancy leads to a range of outcomes, and due to legal restrictions, FSWs often seek unsafe abortions. Aside from the high burden of HIV, little is known about the broader sexual and reproductive health of FSWs in Cameroon.

Methods:

From December 2015 to October 2016, we recruited FSWs aged ≥18 years through respondent-driven sampling across 5 Cameroonian cities. Cross-sectional data were collected through a behavioral questionnaire. Modified-robust Poisson regression was used to approximate adjusted prevalence ratios (aPR) for TOP and current use of effective nonbarrier contraception.

Results:

Among 2,255 FSWs (median age 28 years), 57.6% reported history of unintended pregnancy and 40.0% reported prior TOP. In multivariable analysis, TOP history was associated with current nonbarrier contraceptive use (aPR=1.23, 95% confidence interval [CI]=1.07, 1.42); ever using emergency contraception (aPR=1.34, 95% CI=1.17, 1.55); >60 clients in the past month (aPR=1.29, 95% CI= 1.07, 1.54) compared to ≤30; inconsistent condom use with clients (aPR=1.17, 95% CI=1.00, 1.37); ever experiencing physical violence (aPR=1.24, 95% CI=1.09, 1.42); and older age. Most (76.5%) women used male condoms for contraception, but only 33.2% reported consistent condom use with all partners. Overall, 26.4% of women reported currently using a nonbarrier contraceptive method, and 6.2% reported using a long-acting method. Previous TOP (aPR=1.41, 95%CI=1.16, 1.72) and ever using emergency contraception (aPR=2.70, 95% CI=2.23, 3.26) were associated with higher nonbarrier contraceptive use. Recent receipt of HIV information (aPR=0.72, 95% CI=0.59, 0.89) and membership in an FSW community-based organization (aPR=0.73, 95% CI=0.57, 0.92) were associated with lower use nonbarrier contraceptive use.

Conclusions:

Experience of unintended pregnancies and TOP is common among FSWs in Cameroon. Given the low use of nonbarrier contraceptive methods and inconsistent condom use, FSWs are at risk of repeat unintended pregnancies. Improved integration of client-centered, voluntary family planning within community-led HIV services may better support the sexual and reproductive health and human rights of FSWs consistent with the United Nations Declaration of Human Rights.

Prospective Comparative Study of Oral Versus Vaginal Misoprostol for Second-Trimester Termination of Pregnancy

Background

Various medical methods for second-trimester medical termination of pregnancy (MTP) exist. Misoprostol alone has been used with myriad variations in route and dosage. Comparison between oral and vaginal routes of misoprostol forms the basis of this study.

Methods

This was a prospective comparative study of misoprostol for second-trimester (14-20 weeks) MTP, comparing oral versus vaginal routes. Sixty patients were randomly allotted to two groups; 30 received oral misoprostol 400 µg 4 h up to a maximum of five doses (2000 µg), and 30 received vaginal misoprostol in the same dose and duration. In both groups, oxytocin infusion was started if abortion did not occur. Efficacy of oral versus vaginal misoprostol, induction-abortion interval (AI) and need for surgical intervention were analyzed.

Results

Both groups were well matched in terms of age, parity, previous LSCS, mean gestational age and indication for MTP. Overall mean induction-abortion interval was 19.59 h (21.66 vs. 18.57 h, oral vs. vaginal, respectively), with vaginal group taking lesser time (p 0.09). Sixty percentage in oral group required five doses, while 70% in vaginal group required 3-4 doses of misoprostol (p 0.010). 23.7 versus 6.7% in oral versus vaginal group required check curettage (p 0.038). There were no major complications, and there was only one failure in oral group.

Conclusions

Though both oral and vaginal misoprostol are safe, vaginal route appears to be more efficacious for second-trimester MTP.

The magnitude and severity of abortion-related morbidity in settings with limited access to abortion services: a systematic review and meta-regression

Introduction

Defining and accurately measuring abortion-related morbidity is important for understanding the spectrum of risk associated with unsafe abortion and for assessing the impact of changes in abortion-related policy and practices. This systematic review aims to estimate the magnitude and severity of complications associated with abortion in areas where access to abortion is limited, with a particular focus on potentially life-threatening complications.

Methods

A previous systematic review covering the literature up to 2010 was updated with studies identified through a systematic search of Medline, Embase, Popline and two WHO regional databases until July 2016. Studies from settings where access to abortion is limited were included if they quantified the percentage of abortion-related hospital admissions that had any of the following complications: mortality, a near-miss event, haemorrhage, sepsis, injury and anaemia. We calculated summary measures of the percentage of abortion-related hospital admissions with each complication by conducting meta-analysis and explored whether these have changed over time.

Results

Based on data collected between 1988 and 2014 from 70 studies from 28 countries, we estimate that at least 9% of abortion-related hospital admissions have a near-miss event and approximately 1.5% ends in a death. Haemorrhage was the most common complication reported; the pooled percentage of abortion-related hospital admissions with severe haemorrhage was 23%, with around 9% having near-miss haemorrhage reported. There was strong evidence for between-study heterogeneity across most outcomes.

Conclusions

In spite of the challenges on how near miss morbidity has been defined and measured in the included studies, our results suggest that a substantial percentage of abortion-related hospital admissions have potentially life-threatening complications. Estimates that are more reliable will only be obtained with increased use of standard definitions such as the WHO near-miss criteria and/or better reporting of clinical criteria applied in studies.

Eliminating the high abortion related complications and deaths in Cameroon: the restrictive legal atmosphere on abortions is no acceptable excuse

BACKGROUND

The abortion law in Cameroon is highly restrictive. The law permits induced abortions only when the woman's life is at risk, to preserve her physical and mental health, and on grounds of rape or incest. Unsafe abortions remain rampant with however rare reported cases of persecution, even when these abortions are proven to have been carried out illegally.

DISCUSSION

Available public health interventions are cheap and feasible (Misoprostol and Manual Vacuum Aspiration in post abortion care, modern contraception, post-abortion counseling), and must be implemented to reduce unacceptably high maternal mortality rates in the country which still stand at as high as 596/100.000. Changes in the legal status of abortions might take a long time to come by. Albeit, advocacy efforts must be reinforced to render the law more liberal to permit women to seek safe abortion services. The frequency of abortions, generally clandestine, in this restrictive legal atmosphere has adverse economic, health and social justice implications.

CONCLUSION

We argue that a non-optimal or restrictive legal atmosphere is not an acceptable excuse to justify these high maternal deaths resulting from unsafe abortions, especially in Cameroon where unsafe abortions remain rampant. Implementing currently available, cheap and effective evidence based practice guidelines are possible in the country. Expansion and use of Manual Vacuum Aspiration kits in health care facilities, post-abortion misoprostol and carefully considering the content of post abortion counseling packages deserve keen attention. More large scale qualitative and quantitative studies nationwide to identify and act on context specific barriers to contraception use and abortion related stigma are urgently needed.

Determinants of modern contraceptive practice in Yaoundé-Cameroon: a community based cross sectional study

BACKGROUND

Despite numerous efforts put in place to increase modern contraceptive use in Cameroon as a means to fight maternal and infant mortality, the prevalence of modern contraception has shown only a slow increase and maternal mortality is constantly rising. This paper attempts to identify barriers to contraceptive use in Biyem-Assi, Yaoundé-Cameroon so as to clearly define in which domain and how to intervene concerning contraceptive use in Cameroon.

METHODS

It was a community-based cross sectional study involving a two-steps cluster sampling. Data were collected from November 2014 to April 2015 and analysis done with Epi-Info version 3.5.4. Association between contraceptive use and independent factors was estimated by calculating odds ratio (OR) and confidence interval at 95%. Significance of association in univariate analysis was estimated by calculating the p value with chi2 test. Potential confounder (pregnancy intention) controlled in a multiple logistic regression.

RESULTS

A total of 613 sexually active women were enrolled into the study with a mean age of 27.2 (δ ± 6.2) years. Among the women, 293 (47.8%) were in a union and 530 (86.8%) of them had attended at least a secondary education. Also, 107 (17.5%) responded that their beliefs do not approve contraceptive use and 101 (16.6%) said their partners do not approve contraception. At the moment of data collection, 361 (58.9 [54.9-62.8] %) were currently using a modern contraceptive method. The rate of use of modern contraception was significantly lower in women in a union (OR 0.57, p = 0.0002) and in those with age greater than 30 years (OR 0.45, p = 0.0004). Conversely, the rate of use was significantly higher in women whose partners approved contraception (OR 4.14, p = 0.0000) or when family planning was discussed within the couple (OR 1.93, p = 0.0028).

CONCLUSION

The rate of use of modern contraception in Biyem-Assi Health District is relatively high. Women in a union and those aged greater than 30 years turn to be less likely to use a contraceptive method than the rest of the population meanwhile women whose partner approve contraceptive-use or who discuss about family planning with their partners, are most likely to use a contraceptive method than others. To increase the rate of use of modern contraception in Yaoundé-Cameroon, interventions should target more of couples and not women alone.

[Inventory of unsafe abortions: retrospective study of 451 cases treated in Moulay Ismail Military Hospital of instruction, Meknes, Morocco]

Unsafe abortion is a plague spreading around the world but especially in Africa where it is a lucrative market for traditional practitioners which exposes patients to serious complications including death. Our retrospective study of 451 cases represent an exhaustive sample of this practice in Morocco exploring the reasons why women experience an unsafe abortion, what age group is most affected, conditions and complications inherent in this practice. Our study focuses on the need for intervention before pregnancy by developing the concept of contraception among girls from their early years to minimize these non-health practices.

Clandestine abortion causing uterine perforation and bowel infarction in a rural area: a case report and brief review

Background

An unsafe abortion is defined as a procedure for terminating an unintended pregnancy carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards or both. Majority of these unsafe abortions are carried out in rural areas of developing countries, usually by unskilled persons who do not have proper knowledge of the anatomy of reproductive organs and in unhygienic environments thus leading to various complications.

Case presentation

We discuss the case of a 21 year old female who presented in septic shock after she underwent an unsafe abortion of an 11 weeks pregnancy with uterine wall perforation and bowel injury that required resection.

Conclusion

Unsafe abortion is an important public health problem which accounts for a significant cause of maternal mortality and morbidity in resource poor countries. A high index of suspicion of clandestine abortion with ensuing complications should prevail when faced with a woman of child bearing age with the triad of vaginal bleeding, amenorrhea and pelvic sepsis.