Unsafe Abortion Presentation and Management Outcome Among Sudanese Women

Background: Complications of unsafe abortion remain high in developing countries with a significant morbidity rate and the potential for maternal death. Developing countries need to legalize abortion and improve the care system to reduce abortion-related maternal deaths.

Purpose: The main purpose of the study was to determine the prevalence, methods, complications, and management outcomes of unsafe abortion at Bashair Teaching Hospital. 

Methodology: It was a descriptive, cross-sectional hospital-based study conducted at Bashair Teaching Hospital from October 2021 to March 2022. Data was collected by trained doctors in the emergency clinic and postoperative gynaecology ward. One hundred and twenty-two (122) women with unsafe abortions were included after informed consent.

Results: The prevalence of unsafe abortion was 9.2%. The onset of bleeding was spontaneous in 106(89.9%) and induced in 16(13.1%). The method of induction of abortion was herbal 7(5.7%), drug 4(3.3%), trauma to abdomen 3(2.5%) and manipulation by foreign body 2(1.6%). The duration of bleeding was 1-2 days 63(51.6%), between 3-5 days 38(31.1%) and more than 5 days 21(17.3%).  The complications were shock 19(15.6%), septicaemia 15(12.3%) and uterine perforation 6(4.9%). Discharge well 97(79.5%), discharged after admission to the intensive care unit were23(18.9%), and 2(1.6%) were died.

Conclusions: Unsafe abortion women presented with significant severe bleeding, shock, septicaemia, and fever. The foreign body causes uterine perforation and internal bleeding, so women need laparotomy and blood transfusion. admission to the intensive care unit is high. Maternal death is due to massive bleeding and septicaemia.

An unsafe abortion is completely avoidable. It is still a pandemic and a significant global public health concern [1]. According to the World Health Organization (WHO), an unsafe abortion is performed by someone who lacks the essential skills, takes place in a setting that does not meet the bare minimum of medical standards, or both [2]. 

Unsafe abortion is a healthcare issue that underdeveloped nations frequently ignore. Unsafe abortion practices have virtually not improved despite advances in medical technology. One of the main factors contributing to maternal morbidity and mortality is unsafe abortion [3]. Abortion is more prevalent in Sub-Saharan Africa, where it is typically illegal, dangerous, and contributes significantly to maternal death [4]. Around the world, a significant proportion of women pass away from childbirth and pregnancy-related problems, with low- and middle-income nations accounting for nearly 99.0% of the total [5].  Abortion is one of the leading causes of maternal death. The study found that abortion was responsible for 7.9% of maternal deaths that occurred between 2003 and 2009 in 115 different nations. The number of abortion-related deaths is probably underreported; therefore, it might be higher [6]. Unsafe abortion is one of the main causes of maternal death in low- and middle-income countries, among other things. Abortion can happen naturally or purposely; the latter is also referred to as induced abortion and can be safe or harmful. Abortion (particularly unsafe abortion) can have negative effects on one's health and lead to issues like hemorrhage, infection, and uterine perforation [7].

From 2003 to 2008, the global abortion rate remained stable at 2829/1000 women aged 1544 years, but the percentage of unsafe abortions grew from 44.0% to 49.0% [8]. Due to stringent anti-abortion laws in many South Asian nations, the rate of unsafe abortions is quite high in South Asia (which makes up about one-third of the world's population). Due to the preference for a male kid, the rate of sex-selective abortion is also high in this area [9-10]. Most dangerous abortions take place in impoverished nations where it is forbidden, where access to inexpensive, skilled healthcare providers is limited, or where modern birth control is not widely available [11-14].

 According to the World Health Organization (WHO), nearly all abortions (92%) are safe in industrialized regions, whereas more than half (55%) are dangerous in developing nations. According to other sources, unsafe abortion causes at least 8% of maternal fatalities and has a risk rate of 1/270, according to WHO statistics. Induced abortions are dangerous in 48% of cases worldwide [15]. Unsafe abortion techniques include using a sharp tool or wire (such as an unbent clothes hanger or knitting needle) to try to break the amniotic sac inside the uterus. This technique has the potential to kill by infecting or damaging internal organs, such as the uterus or intestine. Using a huge feather was one of the classic methods since the uterus relaxes during pregnancy and is very simple to puncture [16-19].

Injecting the woman's body with harmful substances including chili pepper mixes and chemicals like alum, Lysol, permanganate, or plant poison. The woman can experience toxic shock and die as a result of this technique [20-21]. Unsafe abortion can result in death and damage to women all around the world [22-24]. Medical care is something that is legally mandated to be given to patients because it could save their lives. Doctors are required by law to report cases of patients who have had any kind of abortion. The risks to women's lives and health increase with every delay in care [25-26].

It was a descriptive prospective cross-sectional hospital-based study conducted at Bashair Teaching Hospital from October 2021 to March 2022. The Study population that was included all women diagnosed with unsafe abortion who came during the study period to the gynecology clinic and emergency room, and they agreed to participate in the study. About 122 women who were diagnosed with unsafe abortions were included. Convenience non-random technique was applied to select the study participants by including all the cases throughout the data collection period (6 months) convenience non-random technique was applied to select the study participants by including all the cases throughout the data collection period (6 months).

Data was collected by direct interview by using a well-structured questionnaire. The participants were interviewed about age, education, gestational age, parity, symptoms of presentation, type of management, and complications.

Statistical analysis was performed via SPSS software (SPSS, Chicago, IL, USA). Continuous variables were compared using the student’s t-test (for paired data) or the Mann–Whitney U test for nonparametric data. For categorical data, a comparison was done using the Chi-square test (X2) or Fisher’s exact test when appropriate. A P-value of less than 0.05 was considered statistically significant.

Written ethical clearance and approval for conducting this research were obtained from the Educational Development Centre (EDC), the ethical committee, and from Sudan Medical Specialization Board Ethical Committee. Written permission was obtained from the administrative authority of Bashair Teaching Hospital, Khartoum state, Sudan. Written consent was obtained from the study participants after a full explanation of the study-related issues and implications. Study data/information was used for research purposes only. The privacy issues were intentionally considered. Confidentiality of participants' data was considered by coding the questionnaire. 

During the study period total number of women admitted to the gynecological department of the hospital was 1319, and 122 were diagnosed with unsafe abortion so the incidence of unsafe abortion is found (122/1319) in approximately 9.2% of all early pregnancy women. Sociodemographic distribution of unsafe abortion, Women aged most below ≤ 19 years were 56.6% while lest distribution between 31 – and 40 years was 10.6%. Most women were housewives 52.5%, and their educational level.

Most were Illiterate women 46.7%, The women from rural areas were 63.9% while from urban areas were 36.1%, 90.2% were married, 5.7% were unmarried, 2.5% were divorced, and 1.6% were widowed. Most women were multipara women 52.5%, primigravida 39.3% and grand multipara 8.2%. Table 1.

Table 1: Sociodemographic characteristics of Unsafe Abortion (n=122).

All women presented with vaginal bleeding, 45(36.9%) fever, 44(36.1%) offensive vaginal discharge, 37(30.3%) abdominal pain and 29(23.8%) expulsion of tissue Table 2.

Table 2: Unsafe abortion symptoms of presentation (n=122).

The duration of bleeding was 1-2 days 63(51.6%) had shock 4(6.3%), septicemia 1(1.6%), uterine perforation 2(3.2%) and no complication 56(88.9%), between 3-5 days 38(31.1%) had shock 5(13.2%), septicemia 10(26.3%), uterine perforation 2(5.3%) and no complication 21(55.3%) and more than 5 days 21(17.3%) had shock 10(47.6%), septicemia 4(19%), uterine perforation 2(9.2%) and no complication 5(23.8%). The estimated amount of bleeding was severe 43(35.2%), had shock17(39.5%), septicemia 13(30.2%), uterine perforation 6(14%) and no complication 7(16.3%), moderate 40(32.8%) had shock 2(5%), septicemia 2(5%), no uterine perforation and no complication 36(90%) and minimal 39(32%) no complication 39(100%) Table 3.

Table 3: Unsafe abortion complications about the duration and degree of bleeding (n=122).

Poor outcome of unsafe abortion (admission to intensive care unit and death) was significantly associated with duration of bleeding 3 days or more, severe amount of bleeding, and complications such as shock and septicemia (P value < 0> 6 days (12(12.4%), had minimal bleeding (39(40.2%), moderate bleeding 38(39.2%), severe bleeding 20(20.6%), 23(18.9%) discharged after admission to the intensive care unit had a duration of vaginal bleeding1-2days5(21.7%),3-5days 10(43.7%%),>6days 8(34.8%), no woman had minimal bleeding, moderate bleeding 2(8.7%), severe bleeding 21(91.3%), and 2(1.6%) died 1(50%) had bleeding >6days and1(50%) bleeding 3-5days both had severe vaginal bleeding. Table 4.

Table 4: Unsafe abortion outcome about the duration and degree of bleeding (n=122).

Outcome of unsafe abortion after management discharge well 97(79.5%) shock 4(4.1%), septicemia 5(5.2%), uterine perforation 6(6.2%) and no complications 82(84.5%), admitted to ICU 23(18.8%) shock 14(60.9%), septicemia 9(39.1%), no uterine perforation and no complications, death 2(1.6%) shock 1(50%) and septicemia 1(50%). The complications of unsafe abortion among the women in this study were significantly common in women with a duration of bleeding 3 days or more and a severe amount of bleeding (P value less than 0.01). Table 5.

Table 5: Unsafe abortion outcome about complications (n=122).

The gestational age at presentation was less than or equal to 12 weeks 43(35.2%), between 13 – 20 weeks 40(32.8%) and more than 20 weeks 39(32%) Figure 1.

Figure 1: Unsafe abortion gestational age at presentation distribution (n=122).

The onset of bleeding was spontaneous in 106(89.9%) and induced in 16(13.1%) Figure 2.

Figure 2: Unsafe abortion onset of bleeding distribution(n=122).

The method of induction of abortion was herbal 7(5.7%), drug 4(3.3%), trauma to abdomen 3(2.5%) and manipulation by foreign body 2(1.6%) Figure 3.

Figure 3: Unsafe abortion method of induction (n=122).

This study found the prevalence of unsafe abortion in this setting during the study period was 9.2%, which is lower than Ngowa, et al [27] in Cameron who reported that the prevalence of unsafe abortion was 26.3%. According to Fusco et al's estimation of the incidence of hazardous abortion in Brazil, the five-year prevalence of abortion was 21.1% among women of reproductive age who had ever terminated a pregnancy, and 16.0% of all abortions were unsafe [28]. This study found a prevalence rate of 24.8% of abortions, which is high [29]. In Brooke et al study, abortion incidence complications methodology was used to estimate levels of induced abortion in Malawi. e. It was estimated that 70,194 induced abortions (range 50,696-89,692) occurred in Malawi in 2009, yielding an abortion rate of 24.0 abortions per 1000 women aged 15-44 (range 17.4-30.7) [30]. All women presented with vaginal bleeding, 36.9% of women presented with fever, 36.1% with offensive vaginal discharge,30.3% presented with abdominal pain, and 23.8% presented with the expulsion of tissue. Similar to Melese et al in Ethiopia [31-32]. Based on varying socioeconomic levels, this study found significant disparities in unsafe abortion procedures. For instance, there is a strong correlation between unsafe abortion and women who work as housewives and have only received an elementary education. These results were consistent with research from Brazil [33] and Mexico [34], where it was discovered that low-income and uneducated women were more likely to undergo unsafe abortions. The legality of abortion differed from state to state in Mexico; Mexico City allows abortions up to 13 weeks gestation, but Brazil allows abortions if the pregnancy was brought on by rape or incest or if the mother's or the fetus' lives were in danger [35].

The method of inducing abortion was herbal 5.7%, drug 3.3%, trauma to the abdomen 2.5%, and manipulation by a foreign body 1.6%. The commencement of bleeding was spontaneous in 89.9% of cases and induced in 13.1% of cases. Contrary to Melese et al.'s findings, which indicated that 3.9% of abortions were patient-induced, the majority of abortions (95.5%) were found to be spontaneous. Eighty-two women, or 67.2%, reported no complications. Shock (15.6%), septicemia (12.3%), and uterine perforation (6(4.9%)) were the consequences. With mild to severe vaginal bleeding, unsafe abortion patients with prolonged vaginal bleeding have a likelihood ratio of 17.812 and a 95% confidence interval of.093(.053-.164) to present with septicemia. 90.954 percent chance of septicemia in women with a Likelihood Ratio of 22.643 95% Confidence interval (CI) of 11.700(6.468-21.164) for septicemia discharge.  Unsafe abortion for intensive care unit (ICU) admission, women with septicemia had a likelihood ratio of 44.051 95% CI 18.833(8.645-41.028). The likelihood ratio between septicemia and maternal death is 4.252,95 % The Congo study's [36] Confidence Interval of 8.643(5.281-14.144) is comparable. Another study revealed that induced abortion-related complications among women who were hospitalized included retained fetal products (50%) as well as bleeding (34%), fever (34%), and other symptoms similar to [37]. The majority of the women had successful outcomes, with 79.5

One of the study's limitations was the fact that only one hospital's data was collected. However, the hospital is unable to offer thorough postabortion treatment since it receives complex cases from other medical facilities. Another drawback was the small number of cases that were found. In our study, the death rate from unsafe abortions was 1.6%, which is less than in other studies. The fact that accessing hospitals in Sudan that perform unsafe abortions is stigmatized to a high degree and that hospitalization leads to a police report because abortion is illegal may be the cause of this. As a result, women may not seek medical attention or may hide the fact that they had an abortion.

According to the study, the three worst consequences include substantial morbidity from unsafe abortion, septicaemia, and uterine perforation. Both the likelihood of maternal mortality and ICU admission are very high. The provision of safe abortion services is not supplied owing to religion; hence contraception should be accessible to help reduce unsafe abortion practices in Sudan. It took a hospital setting and qualified medical staff to manage unsafe abortion consequences like shock, extensive vaginal bleeding, septicaemia, and uterine perforation. Among unsafe abortions, the practice of blood transfusion is lifesaving. When healthcare providers give their patients the best possible care, positive results are attained.

There is a need for health education for women of reproductive age about the urgency of seeking instant care after notice of any signs of unsafe abortion. There is a need for clinical audits on post-abortion care to ensure the implementation of the standard protocol and reduce complications. For managing women who present with unsafe abortion doctors should have and maintain a high index of suspicion that unsafe abortion may have occurred and be alert to the possibility of delayed presentation and rapid decompensation patient may be near missed, early use of intravenous broad-spectrum antibiotic and antipyretics will reduce septicaemia and hyperpyrexia complications, availability of ICU for unsafe abortion and trained staff for early intervention, health worker training and community education. Also, postabortion care services should be available in hospitals, and auditing of the practice of outcomes of unsafe abortion.

This article is our original work. The Submitted manuscripts contain original and authentic results, data, and ideas, that were not published elsewhere. No material from other publications is reproduced in our article. All my co-authors should not submit the same manuscript, in the same language simultaneously to more than one journal. The author of this paper has read and approved the final version submitted.

Ethical clearance

Ethics approval was obtained from the Research and Ethics Committee of the hospital (Bashair Teaching Hospital). Ethical principles of autonomy, beneficence, non-maleficence, and justice, as stipulated in the ethical guidelines of the Sudan Medical Specialization Board (SMSB), and Medical Research Council, were upheld throughout the study. Informed written consent was obtained from every respondent who agreed to participate in the study.

Availability of data and materials 

All data and materials are available when requested.

Competing interest 

The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this paper. No direct or indirect financial interests or conflicts exist and all authors agreed with the content of the manuscript and there are no conflicts of interests between or among them.

Funding

My research project was self-sponsored by me and with the help of my colleagues and co-authors. There was no funding from any institute or organization for this paper.

Authors contribution

All my authors play major roles and real contributions to achieve this project. Bashir Abdeen, Awadalla Abdelwahid, and Hajar participated in data collection and analysis and participated in the manuscript plan, editing, and writing of the article.

Acknowledgments
The authors would like to acknowledge and thank Yousif Suliman Ibrahim for his effort in design, data analysis, and the interviewers for their invaluable contribution to this work, as well as the respondents for their participation in this study.

Abbreviations

CI: Confidence Interval

ICU: Intensive Care Unit 

WHO: World Health Organization

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