Unsafe abortion is a significant but preventable cause of maternal mortality. Although induced abortion has been legal in Zambia since 1972, many women still face logistical, financial, social, and legal obstacles to access safe abortion services, and undergo unsafe abortion instead. This study provides the first estimates of costs of post abortion care (PAC) after an unsafe abortion and the cost of safe abortion in Zambia. In the absence of routinely collected data on abortions, we used multiple data sources: key informant interviews, medical records and hospital logbooks. We estimated the costs of providing safe abortion and PAC services at the University Teaching Hospital, Lusaka and then projected these costs to generate indicative cost estimates for Zambia. Due to unavailability of data on the actual number of safe abortions and PAC cases in Zambia, we used estimates from previous studies and from other similar countries, and checked the robustness of our estimates with sensitivity analyses. We found that PAC following an unsafe abortion can cost 2.5 times more than safe abortion care. The Zambian health system could save as much as US$0.4 million annually if those women currently treated for an unsafe abortion instead had a safe abortion.
In November 1996 the Act on the Termination of Pregnancies (No 92 of 1996) was promulgated. This Act enabled women from the age of twelve years old to decide to terminate their pregnancies before twelve weeks gestation without permission of anybody else. Since February 1997 almost 160 000 terminations of pregnancy have been carried out in South Africa. Little research has been conducted to explore and describe the effect of the termination of pregnancies on women. Two aims were formulated for the research project described in this article: (1) the exploration and description of the women's experience of terminating a pregnancy, and (2) the description of counselling guidelines for caring professionals to assist these women. Participants were included in the sample through purposive sampling. Phenomenological interviews were conducted individually. Data were analysed by means of Tesch's descriptive approach. Counselling guidelines for educational psychologists and other caring professionals to empower the involved were being logically inferred from the results of the interviews. Measures to ensure trustworthiness have been applied in the research and ethical measures have been strictly adhered to during the research. One central theme was identified from the results of the interviews and naive sketches, namely women's experiences of a negative relationship with themselves and other persons as well as their focus on their terminated pregnancies.
BACKGROUND: Complications due to unsafe abortion cause high maternal morbidity and mortality, especially in developing countries. This study describes post-abortion complication severity and associated factors in Kenya. METHODS: A nationally representative sample of 326 health facilities was included in the survey. All regional and national referral hospitals and a random sample of lower level facilities were selected. Data were collected from 2,625 women presenting with abortion complications. A complication severity indicator was developed as the main outcome variable for this paper and described by women's socio-demographic characteristics and other variables. Ordered logistic regression models were used for multivariable analyses. RESULTS: Over three quarters of abortions clients presented with moderate or severe complications. About 65 % of abortion complications were managed by manual or electronic vacuum aspiration, 8% by dilation and curettage, 8% misoprostol and 19% by forceps and fingers. The odds of having moderate or severe complications for mistimed pregnancies were 43% higher than for wanted pregnancies (OR, 1.43; CI 1.01-2.03). For those who never wanted any more children the odds for having a severe complication was 2 times (CI 1.36-3.01) higher compared to those who wanted the pregnancy then. Women who reported inducing the abortion had 2.4 times higher odds of having a severe complication compared to those who reported that it was spontaneous (OR, 2.39; CI 1.72-3.34). Women who had a delay of more than 6 hours to get to a health facility had at least 2 times higher odds of having a moderate/severe complication compared to those who sought care within 6 hours from onset of complications. A delay of 7-48 hours was associated with OR, 2.12 (CI 1.42-3.17); a delay of 3-7 days OR, 2.01 (CI 1.34-2.99) and a delay of more than 7 days, OR 2.35 (CI 1.45-3.79). CONCLUSION: Moderate and severe post-abortion complications are common in Kenya and a sizeable proportion of these are not properly managed. Factors such as delay in seeking care, interference with pregnancy, and unwanted pregnancies are important determinants of complication severity and fortunately these are amenable to targeted interventions.
"OBJECTIVES: Provision of objective, evidence-based counselling in the context of induced abortion services is considered global good practise. However, there is limited understanding over the counselling needs of women accessing abortion services, particularly in sub-Saharan Africa. This study aimed to explore the content and quality of pre-abortion counselling amongst women accessing an abortion service in South Africa as well as client experience of the counselling process. Perceptions of nurse counsellors were also sought. STUDY DESIGN: This was a mixed methods study conducted at a Choice of Termination of Pregnancy clinic based at a district level hospital in KwaZulu-Natal, South Africa. Sixty women requesting an abortion were interviewed via a semi-structured questionnaire. In-depth interviews were conducted with four nurses who provided pre-abortion counselling at the clinic. Interviews were coded for emergent themes and categories. RESULTS: Clinic nurses had widely variable counselling training and experience, ranging from less than 2 months to 8 years, but all clients reported that they had been treated with respect at their counselling session. The group-based counselling format and biomedical and health promotion content did not accommodate clients' differential counselling needs, which included requests for support from women experiencing intimate partner violence (IPV). There was limited provider awareness of client's additional counselling needs. CONCLUSION: Abortion counselling services should be tailored to clients' differential counselling needs. Group-based counselling followed by optional one-on-one counselling sessions is one possible strategy to address unmet client need in South Africa. Provision of abortion provider training in IPV is recommended as well as establishment of referral pathways for women experiencing IPV. IMPLICATIONS: Paying attention to the differential counselling needs of women seeking an abortion should be a key component to the provision of abortion services. In this way, abortion services can provide a gateway to additional support for women living in violent relationships and/or other adverse social circumstances."
"OBJECTIVES: To assess women’s costs of accessing second-trimester labor induction and dilation and evacuation (D&E) services at four public hospitals in Western Cape Province, South Africa. STUDY DESIGN: From April to August 2010, in interviews immediately after completion of their abortion, we asked women about specific direct and indirect costs incurred. We collected information on recurring costs (i.e., per visit) and one-time expenditures and calculated total costs. RESULTS: In total, 194 patients participated (136 D&E; 58 induction). Their median age was 26; 37.6% reported being employed or doing paid work. Most (73.2%) women visited two different facilities, including the study facility, while seeking the procedure. Induction women reported a median of three required visits [interquartile range (IQR) 2.0–3.0] to the study facility, while D&E women reported two required visits [IQR 1.0–2.0]. Twenty-seven percent of women missed work due to the procedure, and few (4.6%) paid for childcare. At each visit, almost all women (180, 92.8%) paid for transportation costs and reported additional one-time costs (177, 91.2%) such as sanitary supplies or doctor’s fees. The total median cost incurred per woman was $21.23 [IQR 11.94–44.68]. Roughly half (49.0%) received help with these costs. CONCLUSIONS: Although technically offered freely or low cost in the public sector, women accessing second-trimester abortion lost income and incurred costs for transport, fees, supplies and childcare. Their total costs could be reduced by minimizing the number of required visits to facilities and freely offering supplies such as sanitary pads and pregnancy tests. IMPLICATIONS: Limited access to second-trimester, safe abortion services in South Africa may result in some women incurring unnecessary costs. Women make multiple visits in attempting to obtain an abortion, often because of facility or health systems requirements, and incur costs for lost income, child care, transport, fees and supplies."
This study was undertaken to assess the risk of being infected with a known sexually transmitted pathogen at the time of presentation for termination of pregnancy. Endocervical and vaginal swabs were collected for the diagnosis of neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis. Single infections were found in 21.5% of the women, with C. trachomatis being the commonest (10.0%). Mixed infections were found in nine women, with trichomoniasis and chlamydial infections in six. During speculum examination, vaginal discharge was observed in 73% of the women. The commonest organism detected in patients with vaginal discharge was C. trachomatis (11.6%), while T. vaginalis (11.1%) was the most common in women without visible vaginal discharge. No significant differences were found when comparing symptomatic and non-symptomatic women. This study strongly recommends that women presenting for termination of pregnancy be screened for STIs and receive relevant sexual health education.
This study aims to evaluate the attitudes of a group of South African parents with a preschool child with Down syndrome (DS) towards prenatal diagnosis (PND) and termination of a Down syndrome-affected pregnancy (TAP). This study employs a qualitative phenomenological approach with the use of semi-structured interviews. Twelve participants were recruited from two state sector hospitals in Cape Town, South Africa. Thematic analysis was used to interpret the data. The participants had a positive attitude towards PND and felt that it was every parent's right to have the option. They considered a benefit of PND the fact that it allowed parents time to prepare for the arrival of a baby with DS. The induced miscarriage risk associated with invasive prenatal testing procedures caused major negative feelings. They were totally opposed to the termination of a Down syndrome-affected pregnancy due to their personal experience, moral, ethical or religious convictions. South African parents of preschool children with Down syndrome are comfortable with PND for Down syndrome; however, they do Not support TAP. These findings will provide health care providers with further insight into the motivations behind the decisions their patients make.
In 1996 the South African government passed new laws allowing termination of pregnancy (TOP) on demand prior to 13 weeks of gestation. In addition, TOP is permitted for socioeconomic or medical reasons for pregnancies between 13 and 20 weeks of gestation. The legislation aimed to reduce morbidity and death resulting from septic abortion related to unsafe TOP. The law states that terminations should be performed by midwives or doctors in designated licensed institutions. National implementation was delayed, with only 32% (92/292) of designated facilities functional in 2000. However, this improved to 62% (189/ 306) by 2003. Confidential maternal death notification became compulsory in South Africa in 1997. The first national report reflected deaths occurring in 1998. Triennial reports followed for the years 1999-2001 and 2002-2004. With the recent release of the 2002-2004 report, it became possible to measure trends in deaths caused by septic abortion. The objective of the present study was to determine septic abortion mortality trends following introduction of TOP legislation. The numbers of deaths from puerperal sepsis were also tabulated.
"BACKGROUND: This study determined the profile of women seeking termination of pregnancy (TOP) in the Free State and whether TOP was used as a family planning method. METHODS: Seven hundred and fifty women (15–47 years old) seeking TOP at the Reproductive Health Unit of the National Hospital in Bloemfontein were included in this cross-sectional study. The women who gave verbal consent completed a questionnaire during counselling. RESULTS: The median age of the participants was 24 years and 77.3% were single. Most participants (73.3%) were not using any family planning method at the time of the study. One-fifth (19.1%) had previously had at least one TOP, while for 80.9% of the participants it was their first visit. Some participants (16.6%) considered TOP a family planning method, 39.7% were unsure and 43.7% indicated that TOP is not a family planning method. Thirty-nine women failed to answer this question. When asked the reason for TOP, 3.5% chose the option “contraceptive method”. CONCLUSIONS: The relatively high percentage of participants who consider TOP a contraceptive method or are unsure, associated with the fact that most were young, single, not using contraception and had applied for induced abortion just because the conception represented an unwanted pregnancy, implies that some of our population is not aware that termination of pregnancy is not a family planning method."
"OBJECTIVES: To describe the magnitude and severity of abortion-related complications in health facilities and calculate the incidence of abortion-related near-miss complications at the population level in three provinces in Zambia, a country where abortion is legal but stigmatized. STUDY DESIGN: We conducted a cross-sectional study in 35 district, provincial, and tertiary hospitals over 5-months. All women hospitalized for abortion-related complications were eligible for inclusion. Cases of abortion-related near-miss, moderate, and low morbidity were identified using adapted WHO near-miss and the prospective morbidity methodology (PMM) criteria. Incidence was calculated by annualizing the number of near-misses and dividing by the population of women of reproductive age. We calculated the abortion-related near-miss rate, abortion-related near-miss ratio, and the hospital mortality index. RESULTS: Participating hospitals recorded 26,723 births during the study. Of admissions for post-abortion care, 2406 (42%) were eligible for inclusion. Near-misses constituted 16% of admitted complications and there were 14 abortion-related maternal deaths. The hospital mortality index was 3%; the abortion-related near-miss rate for the three provinces was 72 per 100,000 women, and the near-miss ratio was 450 per 100,000 live births. CONCLUSIONS: Abortion-related near-miss and mortality are challenges for the Zambian health system. Adapted to reflect health systems capabilities, the WHO near-miss criteria can be applied to routine hospital records to obtain useful data in low-income settings. Reducing avoidable maternal mortality and morbidity due to abortion requires efforts to de-stigmatize access to abortion provision, and expanded access to modern contraception. IMPLICATIONS: The abortion-related near-miss rate is high in Zambia compared with other restrictive contexts. Our results suggest that near-miss is a promising indicator of unsafe abortion, can be measured using routine hospital data, conveniently defined using the WHO criteria and can be incorporated into the frequently utilized prospective morbidity methodology."