State Abortion Policies and Maternal Death in the United States, 2015‒2018

Objectives. To examine associations between state-level variation in abortion-restricting policies in 2015 and total maternal mortality (TMM), maternal mortality (MM), and late maternal mortality (LMM) from 2015 to 2018 in the United States. Methods. We derived an abortion policy composite index for each state based on 8 state-level abortion-restricting policies. We fit ecological state-level generalized linear Poisson regression models with robust standard errors to estimate 4-year TMM, MM, and LMM rate ratios and 95% confidence intervals (CIs) associated with a 1-unit increase in the abortion index, adjusting for state-level covariates. Results. States with the higher score of abortion policy composite index had a 7% increase in TMM (adjusted rate ratio [ARR] = 1.07; 95% CI = 1.02, 1.12) compared with states with lower abortion policy composite index, after we adjusted for state-level covariates. Among individual abortion policies, states with a licensed physician requirement had a 51% higher TMM (ARR = 1.51; 95% CI = 1.15, 1.99) and a 35% higher MM (ARR = 1.35; 95% CI = 1.09, 1.67), and states with restrictions on Medicaid coverage of abortion care had a 29% higher TMM (ARR = 1.29; 95% CI = 1.03, 1.61). Conclusions. Restricting access to abortion care at the state level may increase the risk for TMM.

Experiences of women seeking post-abortion care services in a Regional Hospital in Ghana

Introduction

Abortions remain one of the highest contributors to maternal deaths in Ghana. In 2003, a policy on post-abortion care was introduced to help reduce abortion-related mortality and morbidity. However, depending on the method of pregnancy termination; women encounter varying experiences. This study examines the experiences of women seeking post-abortion care services in a Regional Hospital in Ghana.

Materials and methods

In-depth interview technique was used to collect data from 20 purposively selected post-abortion care clients at the Volta Regional Hospital. Data were analysed manually using a qualitative content analysis technique.

Results

The study found that medical abortion was the main method of pregnancy termination used by women who participated in the study to induce abortion. Spontaneous abortion, however, was attributed mainly to engaging in activities that required the use of excessive energy and travelling on bad roads by pregnant women. The study also revealed that, women do not seek early post-abortion care services due to stigma and poverty.

Conclusions

We found that severity of pain from complications, stigma and financial constraints were factors that influenced women’s decision to seek post-abortion care services. Our findings also suggest that women who experienced spontaneous abortion mainly received financial and emotional support from partners and other family members. To encourage women to seek early post-abortion care services, the Ministry of Health and the Ghana Health Service should take pragmatic steps to educate women on the dangers associated with delay in seeking post-abortion care services and the factors that expose women to spontaneous abortions.

Mortality Synopsis Among Women of Reproductive Age Group in Nigeria: A Hospital-Based Study

PURPOSE

Identification of health problems of women of reproductive age, using a reliable mortality data, is essential in evading preventable female deaths. This study aimed at investigating mortality profile of women of reproductive age group in Nigeria.

MATERIALS AND METHODS

This is a descriptive, retrospective study involving women of reproductive age group of 15-49 years that died at DELSUTH from 1st January 2016 to 31st December 2018. The age, date of death and cause of death were retrieved from the hospital records and subsequently analyzed using SPSS version 21.

RESULTS

One hundred and eighty-seven eligible deaths were encountered in this study, constituting 17.5% of all deaths in the hospital. Twenty four (12.8%) cases were of maternal etiology while 163 (87.2%) were of non-maternal causes. Non-communicable disease, communicable disease and external injuries accounted for 100 (53.5%), 44 (23.5%) and 19 (10.2%) deaths among the non-maternal causes. The mean age and the peak age group are 34.4 years and the 4th decade respectively. The leading specified non-maternal causes of death (in descending order) are AIDS/TB, cerebrovascular accidents (CVA), breast cancer, road traffic accident (RTA), diabetes, perioperative death and sepsis while the leading maternal causes of death are abortion, postpartum hemorrhage, eclampsia and puerperal sepsis.

CONCLUSION

Most deaths affecting WRAG are preventable, with non-maternal causes in excess of maternal causes. There is need for holistic life-long interventional policies and strategies that will address the health need of these women, using evidence-based research findings.

Men's support for abortion in Upper East and Upper West Ghana

The second leading cause of maternal mortality in Ghana is unsafe abortion. Research in Ghana shows that men's support influences women's use of safe abortion services. The aim of this study was to understand what men know about abortion, why they support their partners to seek an abortion, and to identify effective ways to reach men with abortion information. We conducted eleven focus groups and ten in-depth interviews with men of reproductive age in rural Ghana. Inclusion criteria were written consent, age and marital status. Focus groups and interviews were conducted in local languages using a semi-structured guide. Focus groups and interviews were audiotaped, transcribed, translated, computerised and coded for analysis. Most men knew the difference between unsafe and safe abortion and would support their partner to have an abortion. Messages that reinforce safe abortion as acceptable and that address fears of death or barrenness should be developed to educate men about safe abortion. Multiple channels to communicate these messages should be used and include pictures, video or audio for those men who cannot read. Through an intensive intervention inclusive of men, women's access to safe abortion services can be improved in Ghana.

Association of Maternal Age With Severe Maternal Morbidity and Mortality in Canada

IMPORTANCE

Over the past 2 decades, there has been a trend toward increasing maternal age in many high-income countries. Maternal age may lead to greater attendant morbidity and mortality for Canadian mothers.

OBJECTIVE

To investigate the association of maternal age, adjusting for patient-level and hospital-level factors, with severe maternal morbidity (SMM) and maternal death in Canada.

DESIGN, SETTING, AND PARTICIPANTS

A nationwide population-based cohort study of all antepartum, peripartum, and postpartum women and adolescents seen at Canadian acute care hospitals from April 1, 2004, to March 31, 2015. All analyses were completed on September 13, 2018.

EXPOSURES

Maternal age at the index delivery.

MAIN OUTCOMES AND MEASURES

Severe maternal morbidity and maternal death during pregnancy and within 6 weeks after termination of pregnancy.

RESULTS

During the study period, there were 3 162 303 new pregnancies (mean [SD] maternal age, 29.5 [5.6] years) and 3 533 259 related hospital admissions. There were 54 219 episodes of SMM (17.7 cases per 1000 deliveries) in the entire study period, with a 9.8% relative increase from 2004-2005 to 2014-2015, in addition to an increasing proportion of pregnancies to older mothers. Independent patient-level factors associated with SMM included increasing Maternal Comorbidity Index; maternal age 19 years or younger and 30 years or older, with the greatest risk experienced by women 45 years or older (odds ratio [OR], 2.69; 95% CI, 2.34-3.06 compared with maternal age 20-24 years); and lowest income quintile (OR, 1.19; 95% CI, 1.14-1.22 compared with highest income quintile). Hospital-level factors associated with SMM included specific provinces. Independent patient-level factors associated with maternal mortality included increasing Maternal Comorbidity Index, age 40 to 44 years (OR, 3.39; 95% CI, 1.68-6.82 compared with age 20-24 years), age 45 years or older (OR, 4.39; 95% CI, 1.01-19.10 compared with age 20-24 years), and lowest income quintile (OR, 4.14; 95% CI, 2.03-8.50 compared with highest income quintile). Hospital-level factors associated with maternal mortality included lowest hospital pregnancy volume.

CONCLUSIONS AND RELEVANCE

In Canada, maternal age and SMM have increased over the past decade. Results of this study suggest that province of residence, maternal comorbidity, residence income quintile, and extremes of maternal age, especially those 45 years or older, were associated with SMM and mortality. These findings are relevant to prospective parents, their health care team, and public health planning.

ESHRE Capri Workshop Group. Induced abortion

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

Incidence of Induced Abortion in Uganda, 2013: New Estimates Since 2003

BACKGROUND

In Uganda, abortion is permitted only when the life of a woman is in danger. This restriction compels the perpetuation of the practice in secrecy and often under unsafe conditions. In 2003, 294,000 induced abortions were estimated to occur each year in Uganda. Since then, no other research on abortion incidence has been conducted in the country.

METHODS

Data from 418 health facilities were used to estimate the number and rate of induced abortion in 2013. An indirect estimation methodology was used to calculate the annual incidence of induced abortions ─ nationally and by major regions. The use of a comparable methodology in an earlier study permits assessment of trends between 2003 and 2013.

RESULTS

In 2013, an estimated 128,682 women were treated for abortion complications and an estimated 314,304 induced abortions occurred, both slightly up from 110,000 and 294,000 in 2003, respectively. The national abortion rate was 39 abortions per 1,000 women aged 15-49, down from 51 in 2003. Regional variation in abortion rates is very large, from as high as an estimated 77 per 1,000 women 15-49 in Kampala region, to as low as 18 per 1,000 women in Western region. The overall pregnancy rate also declined from 326 to 288; however the proportion of pregnancies that were unintended increased slightly, from 49% to 52%.

CONCLUSION

Unsafe abortion remains a major problem confronting Ugandan women. Although the overall pregnancy rate and the abortion rate declined in the past decade, the majority of pregnancies to Ugandan women are still unintended. These findings reflect the increase in the use of modern contraception but also suggest that a large proportion of women are still having difficulty practicing contraception effectively. Improved access to contraceptive services and abortion-related care are still needed.

Maternal death reviews at Bugando hospital north-western Tanzania: a 2008-2012 retrospective analysis

BACKGROUND

Unacceptably high levels of maternal deaths still occur in many sub-Saharan countries and the health systems may not favour effective use of lessons from maternal death reviews to improve maternal survival. We report results from the analysis of data from maternal death reviews at Bugando Medical Centre north-western Tanzania in the period 2008-2012 and highlight the process, challenges and how the analysis provided a better understanding of maternal deaths.

METHODOLOGY

Retrospective analysis using maternal death review data and extraction of missing information from patients' files. Analysis was done in STATA statistical package into frequencies and means ± SD and median with 95% CI for categorical and numerical data respectively.

RESULTS

There were 80 deaths; mean age of the deceased 27.1 ± 6.2 years and a median hospital stay of 11.0 days [95% CI 11.0-15.3]. Most deaths were from direct obstetric causes (90); 60% from eclampsia, severe pre-eclampsia, sepsis, abortion and anaesthetic complications. Information on ANC attendance was recorded in 36.2% of the forms and gestation age of the pregnancy resulting into the death in 23.8%. Sixty one deaths (76.3%) occurred after delivery. The mode of delivery, place of delivery and delivery assistant were recorded in 44 (72.1), 38 (62.3) and 23 (37.7%) respectively.

CONCLUSION

Routine maternal death reviews in this setting do not involve comprehensive documentation of all relevant information, including actions taken to address some identified systemic weaknesses. Periodic analysis of available data may allow better understanding of vital information to improve the quality of maternity care.

Maternal and neonatal tetanus

Maternal and neonatal tetanus is still a substantial but preventable cause of mortality in many developing countries. Case fatality from these diseases remains high and treatment is limited by scarcity of resources and effective drug treatments. The Maternal and Neonatal Tetanus Elimination Initiative, launched by WHO and its partners, has made substantial progress in eliminating maternal and neonatal tetanus. Sustained emphasis on improvement of vaccination coverage, birth hygiene, and surveillance, with specific approaches in high-risk areas, has meant that the incidence of the disease continues to fall. Despite this progress, an estimated 58,000 neonates and an unknown number of mothers die every year from tetanus. As of June, 2014, 24 countries are still to eliminate the disease. Maintenance of elimination needs ongoing vaccination programmes and improved public health infrastructure.

The Epidemiology of Abortion And Its Prevention in Chile

Mortality by abortion has continuously decreased over the past fifty years in Chile. In fact, maternal death as a result of an induced abortion has become an exceptionally rare phenomenon in epidemiological terms (a risk of 1 in 4 million pregnant women of fertile age or 0.4 per 100,000 life births for abortion of any type, excluding ectopic pregnancy). After abortion became illegal in 1989, deaths related to abortion continued to decrease from 10.8 to 0.39 per 100,000 live births. This scientific fact challenges the common notion that less permissive abortion laws lead to greater mortality associated with abortion.

Report: a study of morbidity of induced abortion data from women belonging to Karachi, Pakistan

The purpose of this study was to evaluate the morbidity of induced abortion in relation to facilities, service providers and social responses of general population of women, from Karachi, Pakistan. Cross-sectional survey, conducted from February to December 2010, through a researcher-administered questionnaire from 61 randomly selected women, who underwent for Induced Abortion, aged 18-50 years. The questionnaire included open and closed ended questions, regarding demography, facilities, service providers and various complications observed. Overall, 98 immediate health problems were reported by 40 (65.5%) of the respondents, 153 late adverse effects or chronic by 46 (75.4%); while 101 mental complications had been reported by 45 (73.8%) of the 61 aborting women; respectively. Private clinics surfaced as the most frequently adopted source as reported by 40.7% of the respondents. Two third majorities had the procedure in satisfactory, good hygienic conditions by skilled professionals. Around 59% of the aborting women were aware of the religious perspective of the subject. Marked incidence of complications had been registered, regardless of type of method adopted, hygienic condition of the procedure or skill of the provider. Although, awareness of religious perspective of the subject was there, still quite a lot opted for abortion. This suggests that strong socioeconomic factors influence women to take peril of such an attempt. It also reveals the existence of a big gap for the awareness services for educating the risks involved to the women's health. Study revealed that services are easily accessible; without any legal, religious or social barriers. Semi or un-educated women, mostly from low socioeconomic sector are opting the procedure in majority, being less aware and stalwartly influenced by environmental factors; hence excessive availability of abortion services should be revisited. Lack of deep awareness of the consequences also contributes for deteriorating future reproductive and mental health. Awareness and counseling services for aborting women, for their health risks, as well as about human perspective of the issue, needs to be initiated, for better management of their reproductive health and rights.

Abortion care in Ghana: a critical review of the literature

The Government of Ghana has taken important steps to mitigate the impact of unsafe abortion. However, the expected decline in maternal deaths is yet to be realized. This literature review aims to present findings from empirical research directly related to abortion provision in Ghana and identify gaps for future research. A total of four (4) databases were searched with the keywords "Ghana and abortion" and hand review of reference lists was conducted. All abstracts were reviewed. The final include sample was 39 articles. Abortion-related complications represent a large component of admissions to gynecological wards in hospitals in Ghana as well as a large contributor to maternal mortality. Almost half of the included studies were hospital-based, mainly chart reviews. This review has identified gaps in the literature including: interviewing women who have sought unsafe abortions and with healthcare providers who may act as gatekeepers to women wishing to access safe abortion services.

[Intentional search and reclassification of maternal deaths in Mexico: The effect on the distribution of causes]

OBJECTIVE

To correct the misclassification and improve the quality of information on maternal mortality in Mexico.

MATERIALS AND METHODS

Using clinical records and verbal autopsies, we studied all deaths certified as maternal deaths as well as a selection of deaths of women of childbearing age whose causes were considered as suspected of hiding a maternal death, all of which occurred during 2011 within Mexico.

RESULTS

The deliberate search of maternal deaths and reclassification allowed the rescue of just over 100 deaths that were not originally registered or coded as maternal and confirmed or corrected the causes of death recorded on death certificates as confirmed maternal deaths. This procedure also allowed the reclassification of 297 maternal deaths of women in the groundwork of the National Institute of Statistics and Geography.

CONCLUSIONS

International Search and Reclassification of Maternal Deaths is a very useful procedure for improving the classification of cases that were not classified as maternal deaths and the effect was greater with the coding of indirect obstetric deaths.

[Clinical study on 67 cases with uterine rupture]

OBJECTIVE

To investigate the incidence, etiology, diagnosis, treatment and outcome of uterus rupture.

METHODS

From January 1999 to May 2013, clinical data of 67 cases with uterine rupture in Woman's Hospital, School of Medicine, Zhejiang University were studied retrospectively.

RESULTS

A total of 67 cases of uterine rupture with 21(+2)-39(+2) gestational weeks out of 128 599 deliveries were recorded giving an incidence of uterine rupture was 0.052 1% (67/128 599) . Cesarean scar rupture were found in 59 cases (88%, 59/67) and noncesarean scar rupture were found in 8 cases (12%, 8/67). The causes of uterine rupture include 60 cases of scar uterus (59 cesarean scar cases and 1 myomyectomy scar case), 2 cases of assisted delivery operation trauma, 2 cases of malformed uterus, 3 cases of unknown causes (all with artificial abortion history).Non obstructive dystocia and improper oxytocin use were found to be related with uterine rupture.Fifty-two cases of cesarean scar spontaneous incomplete rupture were found and repaired during repeated cesarean delivery without maternal and fetal complications. The remaining 15 cases need emergency rescue operation for fetal distress or dead fetus, severe acute abdomen, prepartum or postpartum vaginal bleeding even maternal hypovolemia; 6/15 uterine rupture cases were diagnosed with the history, clinical symptoms and signs, 3/15 cases with ultrasonic found dead fetus in the peritoneal cavity before exploratory laparotomy and 6 cases were diagnosed just during laparotomy.Hysterectomy was done in 10/15 cases and uterine repair in 5/15 cases; there was no maternal death and 12 perinatal fetal death (5 cases of mid-late pregnancy termination for deformed fetus) of the 15 uterine rupture cases.One case with hysterectomy was complicated with stress pancreatitis and dysfunction of liver and kidney and discharged 20 days after operation, the remaining 14 cases were discharged 5-7 days postpartum.One case with repaired malformed uterus got pregnancy 4 years later and delivered a 2 000 g healthy baby by cesarean section at gestational age of 33(+4) weeks.

CONCLUSION

Uterine scar caused by caesarean section or other operations became the leading cause of uterine rupture, assisted delivery operations, history of intrauterine manipulation and uterine malformations were the predisposing risk factors of uterine rupture.

Improving the accuracy of maternal mortality and pregnancy related death

Comparing abortion-related death and pregnancy-related death remains difficult due to the limitations within the Abortion Mortality Surveillance System and the International Statistical Classification of Diseases and Related Health Problems (ICD). These methods lack a systematic and comprehensive method of collecting complete records regarding abortion outcomes in each state and fail to properly identify longitudinal cause of death related to induced abortion. This article seeks to analyze the current method of comparing abortion-related death with pregnancy-related death and provide solutions to improve data collection regarding these subjects.

Benefits of meeting the contraceptive needs of Cameroonian women

(1) In 2013, an estimated 40% of pregnancies in Cameroon were unintended. (2) More than six in 10 women who want to avoid pregnancy either do not practice contraception or use a relatively ineffective traditional method. These women can be said to have an unmet need for modern contraception. (3) Meeting just half of this unmet need would prevent 187,000 unplanned pregnancies each year, resulting in 65,000 fewer unsafe abortions and 600 fewer maternal deaths annually. (4) If all unmet need for modern methods were satisfied, maternal mortality would drop by more than one-fifth, and unintended births and unsafe abortions would decline by 75%. (5) Investing in contraceptive commodities and services to fulfill all unmet need among women who want to avoid pregnancy would result in a net annual savings of US$5.4 million (2.7 billion CFA francs) over what would otherwise be spent on medical costs associated with unintended pregnancies and their consequences. (6) Expanding contraceptive services confers substantial benefits to women, their families and society. All stakeholders, including the Cameroon government and the private sector, should increase their investment in modern contraceptive services.

The medical assumption at the Foundation of Roe v. Wade & its implications for women's health

Too little attention has been paid over the past forty years to the complete lack of a factual record in Roe v. Wade and Doe v. Bolton, and to the Court's fundamental assumption that drove the outcome. The decision and opinions were driven by the medical claim that "abortion was safer than childbirth," which was raised for the first time in the briefs in the Supreme Court without any lower court record. This medical premise directly and profoundly shaped virtually every major aspect of Roe and Doe, including the creation of the trimester system and the prohibition of health and safety regulations in the first trimester. Because of this medical assumption, the Justices extended the right to abortion throughout pregnancy. It was key to the Court's historical rationale for a "right" to abortion. Because of this notion, the Justices gave abortion providers complete discretion to manage any issues of health and safety, and they prohibited public health officials from regulating abortion in the first trimester. This medical assumption was the most consequential factual assumption of the abortion decisions of 1973 and it has been assumed to be true in subsequent abortion decisions by the Court. The notion that "abortion is safer than childbirth" has become even less tenable for at least five reasons: (1) the dysfunctional abortion data reporting system in the United States that relies completely on voluntary reporting; (2) the incomparability of the published abortion mortality rate and the published maternal (childbirth) mortality rate; (3) medical data on the increasing rate of maternal mortality in the second trimester; (4) the growing body of international medical studies finding long-term risks to women from abortion; and (5) maternal mortality data from countries with superior abortion recordkeeping collection and reporting systems, which find a higher rate of abortion mortality than childbirth mortality. These concerns and the growth in international medical data over the past two decades should counsel the Supreme Court to give greater deference to the states in their attempt to protect maternal health.

The challenges procuring of safe abortion care in Botswana

Botswana's national healthcare system has experienced substantial investment as a result of a growing economy and stable government, and improvements in quality and access are notable. Despite these advances, women's reproductive health continues to suffer as a result of unsafe abortion. The personal, financial, and health costs of women seeking dangerous illegal terminations, or crossing national borders to procure a legal abortion, are evident. Twenty-one in-depth, qualitative interviews with Batswana were conducted to gain some insight into the factors which make terminating an unwanted pregnancy difficult in Botswana. This small study demonstrates that there are important socio-cultural constraints, in addition to the legal barriers, that make abortion problematic. These constraints are entrenched in the wider issue of women's rights and status in society.

Reproductive health and the question of abortion in Botswana: a review

The complications of unsafe, illegal abortions are a significant cause of maternal mortality in Botswana. The stigma attached to abortion leads some women to seek clandestine procedures, or alternatively, to carry the fetus to term and abandon the infant at birth. I conducted research into perceptions of abortion in urban Botswana in order to understand the social and cultural obstacles to women's reproductive autonomy, focusing particularly on attitudes to terminating a pregnancy. I carried out 21 interviews with female and male urban adult Batswana. This article constitutes a review of the abortion issue in Botswana based on my research. Restrictive laws must eventually be abolished to allow women access to safe, timely abortions. My findings however, suggest that socio-cultural factors, not punitive laws, present the greatest barriers to women seeking to terminate an unwanted pregnancy. These factors must be addressed so that effective local solutions to unsafe abortion can be generated.

Why women are dying from unsafe abortion: narratives of Ghanaian abortion providers

In Ghana, despite the availability of safe, legally permissible abortion services, high rates of morbidity and mortality from unsafe abortion persist. Through interviews with Ghanaian physicians on the front lines of abortion provision, we begin to describe major barriers to widespread safe abortion. Their stories illustrate the life-threatening impact that stigma, financial restraints, and confusion regarding abortion law have on the women of Ghana who seek abortion. They posit that the vast majority of serious abortion complications arise in the setting of clandestine or self-induced second trimester attempts, suggesting that training greater numbers of physicians to perform second trimester abortion is prerequisite to reducing maternal mortality. They also recognized that an adequate supply of abortion providers alone is a necessary but insufficient step toward reducing death from unsafe abortion. Rather, improved accessibility and cultural acceptability of abortion are integral to the actual utilization of safe services. Their insights suggest that any comprehensive plan aimed at reducing maternal mortality must consider avenues that address the multiple dimensions which influence the practice and utilization of safe abortion, especially in the second trimester.

Measuring unsafe abortion-related mortality: a systematic review of the existing methods

BACKGROUND

The WHO estimates that 13% of maternal mortality is due to unsafe abortion, but challenges with measurement and data quality persist. To our knowledge, no systematic assessment of the validity of studies reporting estimates of abortion-related mortality exists.

STUDY DESIGN

To be included in this study, articles had to meet the following criteria: (1) published between September 1(st), 2000-December 1(st), 2011; (2) utilized data from a country where abortion is "considered unsafe"; (3) specified and enumerated causes of maternal death including "abortion"; (4) enumerated ≥100 maternal deaths; (5) a quantitative research study; (6) published in a peer-reviewed journal.

RESULTS

7,438 articles were initially identified. Thirty-six studies were ultimately included. Overall, studies rated "Very Good" found the highest estimates of abortion related mortality (median 16%, range 1-27.4%). Studies rated "Very Poor" found the lowest overall proportion of abortion related deaths (median: 2%, range 1.3-9.4%).

CONCLUSIONS

Improvements in the quality of data collection would facilitate better understanding global abortion-related mortality. Until improved data exist, better reporting of study procedures and standardization of the definition of abortion and abortion-related mortality should be encouraged.

Ray of hope: opportunities for reducing unsafe abortions!

Unsafe abortion is one of the leading causes of maternal mortality and morbidity which impede the nation in achieving the targets of MDG 5. In the developing world, it is estimated that 13% of all maternal deaths are due to unsafe abortions. Despite having certain liberty in the law and religion, Pakistan has a relatively high prevalence of unsafe abortion. Poverty, unintended pregnancies, ineffective use of contraceptive methods and unawareness about the law are the root causes for the rise in the number of women seeking abortions. Nonetheless, with all these opening points of having permission in the law and religion could direct us that if we just follow them we can reduce the number of unsafe and illegal abortions.Therefore, there is a strong interventions would be required in health and legal aspects, which would decrease maternal mortality and morbidity.

Unintended pregnancy and abortion in Uganda

Unintended pregnancy is common in Uganda, leading to high levels of unplanned births, unsafe abortions, and maternal injury and death. Because most pregnancies that end in abortion are unwanted, nearly all ill health and mortality resulting from unsafe abortion is preventable. This report summarizes evidence on the context and consequences of unintended pregnancy and unsafe abortion in Uganda, points out gaps in knowledge, and highlights steps that can be taken to reduce levels of unintended pregnancy and unsafe abortion, and, in turn, the high level of maternal mortality.

Adolescent maternal mortality in North-west Nigeria

BACKGROUND

Compared to women in their twenties, adolescents are more likely to die during childbirth. Moreover, more than half of women in sub-Sahara Africa deliver their first child before the age of 20 years.

OBJECTIVE

To determine the institutional maternal mortality ratio among adolescents, its risk factors/causes and suggest ways of preventing or reducing the deaths.

METHODS

A descriptive study based on hospital case records of all adolescent maternal deaths at Usmanu Danfodiyo University Teaching Hospital (UDUTH) Sokoto between January 2000 and December 2009.

RESULTS

There were 165 maternal deaths and 3,047 live births among the adolescent mothers within the period giving an adolescent maternal mortality ratio of 5415/100,000 live births. The main causes of death were eclampsia (53.9%), prolonged obstructed labour (15.3%), anaemia (14.5%) and haemorrhage (9.1%). Interestingly, abortion (2.4%) was an uncommon cause of adolescent maternal mortality in this study. Identified risk factors included lack of prenatal care/labour supervision and illiteracy.

CONCLUSION

The adolescent maternal mortality ratio in the institution is remarkably high and is tragically due to preventable causes in most cases. The role of promotion of female education and utilization of family planning,prenatal and intrapartum services in reducing adolescent maternal death cannot be overemphasized.

Alcohol consumption in relation to maternal deaths from induced-abortions in Ghana

INTRODUCTION

The fight against maternal deaths has gained attention as the target date for Millennium Development Goal 5 approaches. Induced-abortion is one of the leading causes of maternal deaths in developing countries which hamper this effort. In Ghana, alcohol consumption and unwanted pregnancies are on the ascendancy. We examined the association between alcohol consumption and maternal mortality from induced-abortion. We further analyzed the factors that lie behind the alcohol consumption patterns in the study population.

METHOD

The data we used was extracted from the Ghana Maternal Health Survey 2007. This was a national survey conducted across the 10 administrative regions of Ghana. The survey identified 4203 female deaths through verbal autopsy, among which 605 were maternal deaths in the 12 to 49 year-old age group. Analysis was done using Statistical software IBM SPSS Statistics 20. A case control study design was used. Cross-tabulations and logistic regression models were used to investigate associations between the different variables.

RESULTS

Alcohol consumption was significantly associated with abortion-related maternal deaths. Women who had ever consumed alcohol (OR (adjusted) 2.6, 95% CI 1.38-4.87), frequent consumers (OR (adjusted) 2.6, 95% CI 0.89-7.40) and occasional consumers (OR (adjusted) 2.7, 95% CI 1.29-5.46) were about three times as likely to die from abortion-related causes compared to those who abstained from alcohol. Maternal age, marital status and educational level were found to have a confounding effect on the observed association.

CONCLUSION

Policy actions directed toward reducing abortion-related deaths should consider alcohol consumption, especially among younger women. Policy makers in Ghana should consider increasing the legal age for alcohol consumption. We suggest that information on the health risks posed by alcohol and abortion be disseminated to communities in the informal sector where vulnerable groups can best be reached.

Septic/unsafe abortion: a preventable tragedy

BACKGROUND

Unsafe abortion is one of the greatest neglected problems of health care in developing countries like Pakistan. In countries where abortions are restricted women have to resort to clandestine interventions to have an unwanted pregnancy terminated. The study was conducted to find out the prevalence of septic induced abortion and the associated morbidity and mortality and to highlight the measures to reduce it.

METHODS

This cross-sectional descriptive study was carried out in Obs/Gyn B Unit, Ayub Teaching Hospital, Abbottabad from January 2007 to December 2011. During this period all the patients presenting with pyrexia lower abdominal pain, vaginal bleeding, acute abdomen, septic or hypovolaemic shock after undergoing some sort of intervention for abortion outside the hospital were included. After thorough history, examination and detailed investigations including high vaginal and endocervical swabs for culture and sensitivity and pelvic ultrasound supportive management was given followed by antibiotics, surgical evacuation of uterus/ major laparotomy in collaboration with surgeon as required. Patients with DIC or multiple system involvement were managed in High Dependency Unit (HDU) by multidisciplinary team.

RESULTS

During the study period out of a total 6,906 admissions 968 presented with spontaneous abortion. There were 110 cases (11.36%) of unsafe abortion, 56.4% presented with vaginal discharge, 34.5% with vaginal bleeding, 21.8% with acute abdomen, while 18.9% in shock and 6.8% with DIC. Forty-nine percent patients used termination as a method of contraception. Mortality rate was 16.36%, leading cause being septicaemia.

CONCLUSION

Death and severe morbidity from unsafe abortions and its complications is avoidable through health education, effective contraception, early informed recognition and management of the problem once it occurs.

The trend in maternal mortality in an upgraded tertiary facility in North Central Nigeria

BACKGROUND

The Millennium Development Goal 5(MDG-5) aims at reducing Maternal Mortality Ratio MMR) by 75% by the year 2015 as compared with the 1990 estimates. There is paucity of recent information on the pattern of maternal mortality in the north central Nigeria.

OBJECTIVE

This study aims to document the trend and causes of maternal deaths at the Federal Medical Centre, (FMC), Lokoja and to suggest ways of improving safe motherhood services at the centre and in Nigeria.

METHOD

This is a review of case records of 44 aternal deaths that occurred between 1st January 2005 and 31 December 2009 at FMC, Lokoja, north central Nigeria.

RESULTS

Forty four maternal deaths occurred and 9496 live births were recorded, giving a Maternal Mortality Ratio (MMR) of 463 per 100,000 live births. The annual MMR decreased from 779/100,000 live births in 2005 to 392/100,000 live births in 2009. The unbooked patients constituted about 68.2% of maternal deaths and about half (56.9%) of women that died were within the age range of 25-29 years. Hypertensive disorders (31.8%), abortion complications (18.2%), obstructed labour/uterine rupture (9.1%) and hemorrhage (9.1%)were the leading causes of death.

CONCLUSION

We observed a decreasing trend in annual maternal mortality at the hospital but more commitment is needed to achieve the MDG-5.

An audit of maternal deaths from a referral university teaching hospital in Nigeria: the emergence of HIV/AIDS as a leading cause

AIMS AND OBJECTIVES

To analyse the characteristics and causes of maternal death in a referral tertiary health facility in Southern Nigeria.

MATERIALS AND METHODS

This is a facility- based review of 184 maternal deaths that occurred from January 2005 to June 2009. Primary causes of death and factors that contributed to maternal death including delay in accessing health care were identified.

RESULTS

During the study period, the Maternal Mortality Ratio (MMR) was 2230/100,000 live births. There was a progressive reduction in the annual MMR from 2901/100,000 live birth in 2005 to 1459/100,000 live birth in 2009. More than four fifth (84.9%) of the maternal deaths occurred among women of low socio-economic class (IV and V). The leading causes of direct maternal deaths (64.1%) were Puerperal sepsis (17.8%), Pre-eclampsia/Eclampsia (15.8%) and complications of unsafe abortion (11.4%). HIV/AIDS was the third commonest overall cause of maternal death (15.2%). Half of the women experienced Type 1 delay (50%), Type 2 and 3 delay occurred in 7.6% and 18.5% of maternal deaths respectively. About two thirds of the women (58.2%) experienced more than one form of delay.

CONCLUSION

Although direct obstetric deaths remain the leading cause of maternal mortality, HIV/AIDS is becoming an important primary cause of maternal mortality in our environment. Organization of health service delivery with an effective referral system and the provision of optimal care for HIV infected women are recommended.

Reductions in abortion-related mortality following policy reform: evidence from Romania, South Africa and Bangladesh

Unsafe abortion is a significant contributor to worldwide maternal mortality; however, abortion law and policy liberalization could lead to drops in unsafe abortion and related deaths. This review provides an analysis of changes in abortion mortality in three countries where significant policy reform and related service delivery occurred. Drawing on peer-reviewed literature, population data and grey literature on programs and policies, this paper demonstrates the policy and program changes that led to declines in abortion-related mortality in Romania, South Africa and Bangladesh. In all three countries, abortion policy liberalization was followed by implementation of safe abortion services and other reproductive health interventions. South Africa and Bangladesh trained mid-level providers to offer safe abortion and menstrual regulation services, respectively, Romania improved contraceptive policies and services, and Bangladesh made advances in emergency obstetric care and family planning. The findings point to the importance of multi-faceted and complementary reproductive health reforms in successful implementation of abortion policy reform.

Maternal mortality in Niger: a retrospective study in a high risk maternity

OBJECTIVE

This study analyzes maternal deaths in a tertiary maternity in Niamey, Niger.

METHODS

This is a retrospective study covering the period of one year, from January 1 to December 31 2007. The setting for this study was the Maternity Issaka Gazobi, a tertiary maternity referral centre in the city of Niamey, Niger. Data encompasses all hospital maternal deaths attributable to obstetric causes. The data were abstracted from emergency room, delivery rooms and hospitalization units' patient files.

RESULTS

During the study period a total of 4,582 live births were registered with a total count of 121 maternal deaths, yielding a maternal mortality ratio of 2,640/100,000 live births. The mean age of deceased mothers was 26 years with a range of 15 to 43 years, and 46% of them were 15-24 years old. The most common risk factors for maternal death were primiparity (33%), haemorrhage (30%) and anaemia (22%). Most of the maternal deaths occurred post-partum (70%), 24 died peripartum, 6 died from miscarriage or abortion in association with excessive bleeding or septic complications, and one died from etopic pregnancy. Among most deaths, the burden of morbidity was important, with 57.9% of patients admitted in a state of shock from eclampsia or acute cerebral malaria.

CONCLUSIONS

The high rate of mortality in this hospital testifies to the high morbidity of the patients, with anemia as an important risk factor. Maternal mortality in Niger remains high due to socio-economic factors, lack of access to quality care, and insufficient number of qualified health personnel.

Socioeconomic inequalities in outcome of pregnancy and neonatal mortality associated with congenital anomalies: population based study

OBJECTIVES

To investigate socioeconomic inequalities in outcome of pregnancy and neonatal mortality associated with congenital anomalies.

DESIGN

Retrospective population based registry study.

SETTING

East Midlands and South Yorkshire regions of England (representing about 10% of births in England and Wales).

PARTICIPANTS

All registered cases of nine selected congenital anomalies with poor prognostic outcome audited as part of the United Kingdom's fetal anomaly screening programme with an end of pregnancy date between 1 January 1998 and 31 December 2007.

MAIN OUTCOME MEASURES

Socioeconomic variation in the risk of selected congenital anomalies; outcome of pregnancy; incidence of live birth and neonatal mortality over time. Deprivation measured with the index of multiple deprivation 2004 at super output area level.

RESULTS

There were 1579 fetuses registered with one of the nine selected congenital anomalies. There was no evidence of variation in the overall risk of these anomalies with deprivation (rate ratio for the most deprived 10th with the least deprived 10th: 1.05, 95% confidence interval 0.89 to 1.23). The rate ratio varied with type of anomaly and maternal age (deprivation rate ratio adjusted for maternal age: 1.43 (1.17 to 1.74) for non-chromosomal anomalies; 0.85 (0.63 to 1.15) for chromosomal anomalies). Of the nine anomalies, 86% were detected in the antenatal period, and there was no evidence that this varied with deprivation (rate ratio 0.99, 0.84 to 1.17). The rate of termination after antenatal diagnosis of a congenital anomaly was lower in the most deprived areas compared with the least deprived areas (63% v 79%; rate ratio 0.80, 0.65 to 0.97). Consequently there were significant socioeconomic inequalities in the rate of live birth and neonatal mortality associated with the presence of any of these nine anomalies. Compared with the least deprived areas, the most deprived areas had a 61% higher rate of live births (1.61, 1.21 to 2.15) and a 98% higher neonatal mortality rate (1.98, 1.20 to 3.27) associated with a congenital anomaly.

CONCLUSIONS

Antenatal screening for congenital anomalies has reduced neonatal mortality through termination of pregnancy. Socioeconomic variation in decisions regarding termination of pregnancy after antenatal detection, however, has resulted in wide socioeconomic inequalities in liveborn infants with a congenital anomaly and subsequent neonatal mortality.

Unsafe abortion and its ethical, sexual and reproductive rights implications

BACKGROUND

Unsafe abortion is an important cause of maternal mortality and morbidity, particularly marked in developing countries with restrictive abortion laws. It has both bioethical and human rights implications, violating their key principles and components.

OBJECTIVE

To highlight the magnitude of complications of unsafe abortion and examine the legal,bioethical, sexual and reproductive right implications of unsafe abortion as well as to review post abortion care (PAC) in Nigeria.

DATA SOURCE

Information derived from online web-search, literature review of articles from learned journals, serials and monographs from local and supra-national agencies working on abortion, and reproductive health.

RESULTS

About 20 million unsafe abortions are performed annually globally resulting in about 80, 000 maternal deaths. Asia and Africa have the highest number of maternal deaths. In Nigeria, 760, 000 abortions are performed annually. Abortion law in Nigeria is restrictive. Unsafe abortion violates three key bioethical principles at micro and mega-ethical levels. It also violates eleven of the twelve components of sexual and reproductive rights. PAC is approved as an effective approach to reducing abortion morbidity and mortality and promoting women's reproductive rights.

CONCLUSION

Stakeholders can promote the ethical, sexual and reproductive rights of women through the following interventions: advocacy, liberalization of restrictive abortion law, training of health workers on PAC services, inter-organisational collaboration, development of right based code of ethics and inclusion into medical training curriculum. Socio-economic empowerment of women, provision of PAC services equipments in health facilities, and improvement of access to quality family planning services will also help promote the rights of women.

Maternal mortality and morbidity of unsafe abortion in a university teaching hospital of Karachi, Pakistan

OBJECTIVE

To study the mortality and morbidity of unsafe abortion in a University Teaching Hospital.

METHODS

A cross-sectional, descriptive study was conducted in Department of Obstetrics and Gynaecology, Unit III, Dow Medical College and Civil Hospital Karachi from January 2005 to December 2009. Data regarding the sociodemographic characteristics, reasons and methods of abortion, nature of provider, complications and treatment were collected for 43 women, who were admitted with complications of unsafe abortion, and an analysis was done.

RESULTS

The frequency of unsafe abortion was 1.35% and the case fatality rate was 34.9%. Most of the women belonged to a very poor socioeconomic group (22/43; 51.2%) and were illiterate (27/43; 62.8%). Unsafe abortion followed an induced abortion in 29 women and other miscarriages in 14 women. The majority of women who had an induced abortion were married (19/29, 65.5%). A completed family was the main reason for induced abortion (14/29; 48.2%) followed by being unmarried (8/29, 27.5%) and domestic violence in 5/29 cases (17.2%). Instruments were the commonest method used for unsafe abortion (26/43; 68.4%).The most frequent complication was septicaemia (34; 79%) followed by uterine perforation with or without bowel perforation (13, 30.2%) and haemorrhage (9; 20.9%). Majority of induced abortions were performed by untrained providers (22/26; 84.6%) compared to only 3/14 cases (21.4%) of other miscarriages (p = 0.0001).

CONCLUSION

The high maternal mortality and morbidity of unsafe abortion in our study highlights the need for improving contraceptive and safe abortion services in Pakistan.

Capturing the context of maternal deaths from verbal autopsies: a reliability study of the maternal data extraction tool (M-DET)

Background

The availability of quality data to inform policy is essential to reduce maternal deaths. To characterize maternal deaths in settings without complete vital registration systems, we designed and assessed the inter-rater reliability of a tool to systematically extract data and characterize the events that precede a nationally representative sample of maternal deaths in India.

Method/Principal Findings

Of 1017 nationally representative pregnancy-related deaths, which occurred between 2001 and 2003, we randomly selected 105 reports. Two independent coders used the maternal data extraction tool (questions with coding guidelines) to collect information on antenatal care access, final pregnancy outcome; planned place of birth and care provider; community consultation, transport, admission, hospital referral; and verification of cause of death assignment. Kappa estimated inter-rater agreement was calculated and classified as poor (K≤0.4), moderate (K = 0.4-≤0.6), substantial (K = 0.6-≤0.8) and high (K>0.8) using the criteria from Landis & Koch. The data extraction tool had high agreement for gestational age, pregnancy outcome, transport, death en route and admission to hospital; substantial agreement for receipt of antenatal care, planned place of birth, readmission and referral to higher level hospital, and whether or not death occurred in the intrapartum period; moderate to substantial agreement for classification of deaths as direct or indirect obstetric deaths or incidental deaths; moderate agreement for classification of community healthcare consultation and total number of healthcare contacts; and poor agreement for the classification of deaths as sudden deaths and other/unknown cause of death. The ability of the tool to identify the most-responsible-person in labour varied from moderate agreement to high agreement.

Conclusions

This data extraction tool achieved good inter-rater reliability and can be used to collect data on events surrounding maternal deaths and for verification/improvement of underlying cause of death.

Morbidity and mortality due to unsafe abortion in Pakistan

OBJECTIVES

To determine the frequency of women who had undergone an unsafe abortion and attended a tertiary care hospital in Pakistan with complications.

METHODS

Patients with a history of termination at a gestational age of less than or equal to 22 weeks were included in the study.

RESULTS

Of 230 women who met the inclusion criteria, 50 (21.7%) patients had undergone an unsafe abortion and attended the hospital with associated complications. Unintended pregnancy was the reason for the abortion in 82% of women (n=41). Eighteen (36%) underwent terminations performed by doctors, 18 (36%) by Lady Health Visitors (n=18), 10 (20%) by an untrained birth attendant (Dai), and 4 (8.0%) by nurses. Dilatation and evacuation procedures were performed in 28 (56.0%) women, while a Laminaria tent prior to evacuation was used in 18 (36.0%). Major complications included uterine perforation and gastrointestinal injury, observed in 27 (54.0%) women. Hemorrhage was observed in 13 (26.0%) women with retained products of conception after incomplete abortion. Six (12.0%) women died.

CONCLUSION

Healthcare providers performed the majority of terminations. To prevent maternal mortality, improved skills through refresher courses and workshops on safer methods are needed.

Prevention of unsafe abortion: analysis of the current situation and the task ahead

An evaluation of the current situation regarding implementation of the plans of action for the prevention of unsafe abortion shows that more than half of the countries selected for the initiative have progressed as planned or have surpassed expectations. The greatest barriers to faster progress have been insufficient resources or infrastructure and the sensitivity of the subject matter, as well as lack of a more active commitment from the societies of obstetrics and gynecology and their members. The most frequently mentioned facilitating factors were the strength of the project/FIGO leadership, the commitment of the collaborating agencies, and incorporation of the activities of the plans of action into the agenda of the Ministry of Health. The commitment of the societies of obstetrics and gynecology and a good relationship between these societies and their Ministry of Health were also mentioned as being important facilitating factors. On the operational side, the monitoring visits and the regional workshops were seen as facilitators by over three-quarters and two-thirds of the countries, respectively. FIGO is committed to continue providing technical and political support to the societies involved in this initiative, promoting strategies to overcome the barriers while taking full advantage of the facilitating factors.

[Scientific evidence on the legalization of abortion in Mexico City]

BACKGROUND

On April 24 2007, abortion before 12 weeks became legal in Mexico City. The arguments for this decision were: diminish the maternal morbidity and mortality, avoid a "severe health problem" and accomplish the women's physical, mental and social well being.

OBJECTIVE

To analyze the scientific evidences that support or reject this arguments.

MATERIAL AND METHOD

Retrospective study realized by bibliographic search of electronic data basis and Internet portals of interested groups.

RESULTS

Mexico is considered by the World Health Organization, one of the countries in the world with low maternal mortality rates (<100/100,000 live births). The main causes are: preeclampsia-eclampsia, pregnancy related hemorrhage, complications of pregnancy, delivery and puerperium, and other causes (92.2 to 93.1%). In 2007, the Health Services of Mexico City reported 11 deaths (0.03% of the total maternal deaths) associated with "non-spontaneous abortion". In the hospitals of the Mexican Institute of Social Security, maternal deaths as consequence of induced abortions were, approximately, three every year. The evidences used as arguments in favor of abortion come from studies performed in Sub-Saharan African countries, which do not apply to Mexico.

DISCUSSION

The scientific evidences show that induced abortion has important psychological sequels in women, a higher frequency of illegal drug abuse, alcoholism, child abuse, low birth weight in the following pregnancy, greater risk of subsequent miscarriage and greater mortality rate.

CONCLUSIONS

There are no scientific evidences to support the arguments used for the legal approval of abortion in Mexico City.

Unsafe abortion in lagos, Nigeria: a continuing tragedy

OBJECTIVES

To assess the incidence, pattern of presentation and management of complications resulting from unsafe abortion as well as the associated demographic variables at the Lagos Island Maternity Hospital.

PATIENTS AND METHODS

A cross sectional survey of all cases with complicated induced abortion was carried out between 1st August 2005 and 31st January 2007.

RESULTS

The majority of the patients were young 21.7% were teenagers between 14 and 19 years while 32.6% were in the 20-24 year age group. The majority (64.0%) were single while 30.9% were married, 1.7% were divorced, while 3.4% were separated. Teenagers and single women were more likely to obtain their abortion late (above 12 weeks gestation). 81.2% of the patients knew about modern methods of contraception but only 34.5% had ever used contraception and only 8.6% were using contraception when they became pregnant. Medical doctors were the abortionists in 46.9% of the cases, followed by nurses (17.7%) and traditional practitioners. Retained products of conception was the commonest complication (77.1%) followed by anaemia (48.6%) and sepsis (44.6%). Evacuation of the uterus was the commonest surgical procedure done. There were 16 maternal deaths giving a case fatality rate of 9.14%. Sepsis was the commonest cause of death.

CONCLUSION

Unsafe abortion remains a serious concern to the health of women. Efforts need to be maximised at preventing unwanted pregnancy by making contraceptive services easily accessible to women. Effective post abortion care services need to be put in place.