High severity of abortion complications in fragile and conflict-affected settings: a cross-sectional study in two referral hospitals in sub-Saharan Africa (AMoCo study)

Abstract

Background Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR). Methods We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records’ reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity. Results We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%). Conclusion Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.

Testing a framework for evaluating the quality of post-abortion care: an analysis using data from the AMoCo study in two sub-Saharan African hospitals in humanitarian settings

“…In contrast, while the prevention of surgical-related infection seems to be well implemented in the Nigerian hospital, only 40% of women receiving instrumental uterine evacuation received a prophylactic antibiotic in the CAR hospital. This preventative intervention is even more important in this context of restrictive abortion laws where women may have had unsafe instrumental abortions [10]. Moreover, as found in other African studies[60, 61], we identi ed some overprescription of antibiotics in both settings, even though some of these prescriptions might have been justi ed but not documented in the patient le.…”

“…Women with threatened abortions were excluded. Eligible women were identi ed by the study clinicians through hospital registers tracking and participations to daily gynecologic-obstetrics clinical meetings [10]. After checking their eligibility, women were included in the study after an informed opt-out consent process.…”

“…Alternatively, the prescription of blood transfusions outside the guidelines' indications may suggest the need to adapt these recommendations to the context. Indeed, women of reproductive age in this fragile State of Jigawa have some of the worst nutritional and anemia indicators in the country [10,64]. The fact that resources in this hospital are not as restricted as in other hospitals not supported by international organizations[60] may have enabled clinicians to adapt their practice to the speci cities of women in this state.…”

“…The disruption of health systems affecting availability of and access to routine contraceptive and safe abortion services[8] as well as the higher risk of exposure to sexual violence and transactional sex can increase the risk of unwanted pregnancies leading to unsafe abortion [9]. In addition, the deterioration of the access to adequate PAC at all levels of the health system as well as the increased food insecurity leading to chronic underlying anemia can contribute to increase the severity of complications from any abortion (spontaneous or induced) [10]. Therefore, ensuring provision of high quality PAC is as critical in these contexts as in stable contexts [11].…”