Unsafe Abortion . And post abortion care

A medical materials for post graduate family medicine

1. Unsafe Abortion Dr Zainab M Hassan Department of Family Medicine FMCJ 1 9/25/2024

2. Outline Introduction Definition Epidemiology Abortion laws in Nigeria Risk factors Methods of unsafe abortion Clinical presentation Diagnosis Management Post Abortion Care (PAC) Prevention Conclusion References 9/25/2024 2

3. Pre Test 1. Providers of unsafe abortion includes a) Chemist b) Self c) Nurses d) All of the above e) None of the above 9/25/2024 3

4. Pre Test 2.The following are risk factors for unsafe abortion except a) Low socioeconomic status b) Stigma for unwanted pregnancy c) Knowledge about safe abortion services d) Desire to pursue education e) Avoiding parental disappointment 9/25/2024 4

5. Pre Test 3. Methods of unsafe abortion includes a) Oral toxic fluids b) Vaginal herbal preparations c) Intra-uterine foreign bodies d) None of the above e) All of the above 9/25/2024 5

6. Pre Test 4. Late complication of unsafe abortion include a) Bleeding b)Infertility c) sepsis d) perforation of the uterus e) Cervical tear 9/25/2024 6

7. Pre Test 5. Barriers to safe abortion includes a) Restricted abortion laws b) Cultural and religious misconceptions c) Poverty d) All of the above e) None of the above 9/25/2024 7

8. Pre Test 6. One of the following is a component of safe Post Abortion Care a) Restricted abortion laws b) Training of practitioners on safe abortion methods c) Health education on reproductive health in school d) Contraceptive and family planning services e) Better access to healthcare services 9/25/2024 8

9. Introduction Abortion is the expulsion or removal of the products of conception before the age of viability. Abortion whether safe or unsafe is a common event globally. Unsafe abortion is one of the leading causes of maternal morbidity and mortality that is preventable. 9/25/2024 9

10. Introduction In sub-Saharan Africa abortion is only legal when performed to save the mother. Abortion remain clandestine in Nigeria as such the prevalence of unsafe abortion is on rise. Therefore many women are treated for complications of unsafe abortion 9/25/2024 10

11. Definition Unsafe abortion as a procedure of pregnancy termination either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards or both (WHO). 9/25/2024 11

12. Epidemiology Globally, 210 millions women become pregnant yearly About 80 million of these pregnancies are unplanned 46 millions of these pregnancies are terminated each year and 19 million end in unsafe abortion More than 97% of unsafe abortion takes place in developing countries It is a neglected public health problem that contribute about 13% of maternal death worldwide. 9/25/2024 12

13. Epidemiology In Africa over 4 million unsafe abortion are carried out yearly mostly on poor , rural and young women lacking information on the availability of safe abortion care About 99% of all abortion in Africa is unsafe and the risk of maternal death is one in every 150 procedures The society for gynaecology and obstetrician of Nigeria estimated that about 20,0000 Nigerian women die from unsafe abortion each year Only 16 percent of all women of reproductive age use any contraceptive, And even lower percentage (11%) use a modern method. 9/25/2024 13

14. Epidemiology The prevalence of unsafe abortion is associated with restricted abortion laws, poor quality of services, lack of community awareness, poverty, social inequity and denial of women’s human right. 9/25/2024 14

15. Abortion laws in Nigeria Abortion is heavily restricted throughout Nigeria, O ne set of laws apply in different parts of Nigeria . T he laws provide room for interpretation. T he generally accepted understanding across the nation, among policy makers, providers and women themselves is that, abortion is legally prohibited with limited exception where the woman’s pregnancy endangers her life 15 9/25/2024

16. Abortion laws in Nigeria In the Southern Nigeria, the relevant provisions are sections 228, 229, 230, 297, and 328 of the Criminal Code.18 In the North, the relevant provisions are sections 232, 233, 234, 235 and 236 of the Penal Code.19 For the states that have adopted the Sharia Legal System, abortion is also criminalized by the Sharia penal code law. 16 9/25/2024

17. Risk factors for unsafe Abortion Lack of availability/knowledge of safe abortion services Socioeconomic conditions/status unemployment lack of partner support of pregnancy schooling non readiness to cater for a baby Religious/cultural misconception of safe abortion Stigma of unwanted pregnancy 9/25/2024 17

18. Risk factors Desire to bear children only after marriage Avoiding parental disappointment/resentment Desire to pursue education 9/25/2024 18

19. Methods of unsafe Abortion Oral toxic fluids like bleach Injectable medication Vaginal herbal preparation Intrauterine foreign bodies Trauma to the abdomen D and C by unskilled providers 9/25/2024 19

20. Examples of providers of unsafe abortion Chemist/pharmacist Nurses Medical Doctors Self Traditional herbalist 9/25/2024 20

21. Clinical features Symptoms of unsafe abortion vary depending on various factors such as stage of the pregnancy, methods used and overall health condition Common symptoms include; Abdominal pain Hemorrhage Fatigue Dizziness Fainting spells Features of sepsis Features of shock 9/25/2024 21

22. Diagnosis Accurate diagnosis is crucial through, history, physical examination and utilizing appropriate diagnostic test This involves assessing various indicators such as; abnormal bleeding, pelvic pain infection Other complications that may arise as a result of improperly performed abortion 9/25/2024 22

23. Management Principle of management Quick History and Physical Examination Resuscitation Relevant Investigations Definitive Treatment Post Abortion Care/Rehabilitation Follow Up 23 9/25/2024

24. Management Treatment of shock Call urgently for help Ensure airway is open and patient is breathing well Nurse in left lateral position Set up IV Normal saline with double wide bore canula (16-18G) Keep her warm Elevate her legs Monitor vital signs and blood loss Oxygen at 6–8L/minute 24 9/25/2024

25. Management Pass a urethral catheter to monitor intake and output Group and crossmatch at least 2 pints of blood for transfusion Administer antibiotics intravenously for the next 48 hours When the patient is stable, remove protruding POC, perform MVA 25 9/25/2024

26. Management Treatment of intra abdominal injury Monitor vital signs, ensure patient is stable Oxygen 6‑8L/minute Nothing by mouth: Administer IV fluids and antibiotics Laparotomy for repair of any intra- abdominal injury (uterus, intestines, etc.) 26 9/25/2024

27. Complications of unsafe abortion Immediate Complications Incomplete Abortion Hemorrhage Infection – Sepsis Tears in the cervix Perforation of uterus Injury to viscera – bowel, bladder etc Acute renal failure 27 9/25/2024

28. Complications Long term disability Chronic pelvic pain Pelvic inflammatory disease Tubal blockage leading to secondary infertility Ectopic pregnancy Psychological trauma DEATH 28 9/25/2024

29. Post Abortion Care (PAC) It is a composite care given to a woman after an abortion process and the partner, where appropriate, in order to prevent future risk of unwanted pregnancy and its complications. 9/25/2024 29

30. Post Abortion care (PAC) Components 1.Emergency treatment services: Treat incomplete and unsafe abortion and potentially life- threatening complications. 2.Contraceptive and family planning services: Help women prevent an unwanted pregnancy or practice birth spacing. Short term; 2-3 months to prevent another pregnancy until it desired. Provides space for the woman to recover from her morbidity. Gives time for investigation of cause of abortion {if it was a spontaneous miscarriage}. 30 9/25/2024

31. PAC 3. Reproductive and other health services: Preferably provided on-site, or via referrals to other accessible facilities in providers’ networks. Treatment of STIs Screening for cervical cancers Links to other health services. 31 9/25/2024

32. PAC 4.Community and service provider partnerships. Prevent unwanted pregnancies and unsafe abortion; Mobilize resources to help women receive appropriate and timely care for complications from abortion; Ensure that health services reflect and meet community expectations and needs. 5. Counseling Identify and respond to women’s emotional and physical health needs and other concerns . 9/25/2024 32

33. Barriers of safe abortion Social factors religious and cultural Law restricted abortion laws and lack of awareness Lack of accessibility to quality and skilled provider of safe abortion Economy poverty 9/25/2024 33

34. Prevention Health education on reproductive health in schools Increasing contraceptive use through provision of accurate information and proper use of contraception In countries where abortion is legal providing women with better access to health centres that perform abortion. Training of practitioners on safer abortion methods Liberalization of abortion laws to allow services to be provided openly by skilled practitioners. 9/25/2024 34

35. conclusion Unsafe abortion is a preventable cause of maternal morbidity and mortality. As such preventing unintended pregnancies through proper use of contraception, provision of adequate reproductive health education in schools and better access to healthcare as well as liberalization of abortion laws to allow services to be provided openly can go a long way to reduce the rate of abortion related morbidity and mortality. 9/25/2024 35

36. References Haddad LB, Nour NM, unsafe abortion; unnecessary maternal mortality Review in Obstetric and Gynaecology , 2009,2(2); 122 Gebremedlin M, Semahegin A, Usmael T, Tesforge G, unsafe abortion and associated factors among reproductive aged women in sub-Saharan Africa;a protocol for systematic review and meta analysis, systematic reviews 2018; 7;1-5 Raufu A.unsafe abortion cause 20,0000 deaths a yearin Nigeria. BMJ, 2002; 325(737); 988. Okorie PC, Abayomi OA, Abortion laws in Nigeria; a case for reform. Annual survey of international and comparative law. 2019, 23(1); 165. Helen Bickerstaff and Louisse C Kenny, Ten Teachers Gynaecology,20 th edition, New York,2017. 9/25/2024 36

37. References Bankole, A., Adewole, I., Hussain, R., Awolude, O., Singh, S., Akinyemi, J. (2015). The incidence of abortion in Nigeria. International Perspectives on Sexual and Reproductive Health, 41(4):170–181. World Health Organization. (2014). Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF,UNFPA, The World Bank and the United Nations Population Division. Geneva: WHO. Unsafe Abortion: Global and Regional estimates of the incidence of Unsafe Abortion and associated mortality in 2008, 3rd ed. Geneva, World Health Organization, 2011. 9/25/2024 37

38. References Bamniya A, Verma S. The study of knowledge, attitude and practice about abortion and technology at the tertiary centre in the region of Mewar, Rajasthan, India. Int J Reprod Contraception, Obstet Gynecol . 2018;7(8):3320–4. Ganatra B, Tunçalp Ö, Johnston HB, Johnson BR, Gülmezoglu AM, Temmerman M.From concept to measurement: Operationalizing WHO’s definition of unsafe abor1.Ganatra B, Tunçalp Ö, Johnston HB, Johnson BR, Gülmezoglu AM, Temmerman M.From concept to measurement: Operationalizing WHO’s definition of unsafe abortion.Vol . 92, Bulletin. Bull World Health Organ [Internet]. 2014;92(3):155. [cited 2020 04 23].Available from: doi : http://dx.doi.org/10.2471/BLT.14.136333 38 9/25/2024

39. 39 THANK YOU FOR LISTENING 9/25/2024