Reducing Mortality from Unsafe Abortion in Kenya Through Increased Access to Post-Abortion Care

December 18, 2013

By Michael Mutua, Data Analyst, APHRC

The recent Kenya Demographic and Health Survey (KDHS) showed  a marked increase in maternal mortality ratio from 414 to 488 women per 100,000 live births between 2003 and 2009 [1]. While induced abortion is the leading known cause of maternal mortality, Kenya has the highest induced abortion rate in East Africa, a region known for generally high abortion rates[2].

In developing countries, an estimated 5 million women are admitted every year to healthcare facilities with complications from unsafe abortion and this presents a high cost to the healthcare system, especially in these resource constrained countries[3].  In Kenya, this admission rate is estimated at over 20,000 women annually[4]. Unsafe abortion accounts for up to 35% of all maternal mortalities[5, 6] in Kenya. Two years short of the end of the millennium development goals period, urgent measures to reduce the risks of unsafe abortion are critical.

This policy brief aims at providing evidence for the Reproductive and Maternal Health Services Unit (RMHU) in the Ministry of Health and other non-governmental healthcare partners to adopt measures aimed at reducing maternal mortality due to unsafe abortions in Kenya by increasing capacity at lower level facilities and early detection and treatment of complications from unsafe abortion as well as establishment of a referral system by 2015.  The policy brief outlines the current state maternal health in Kenya and makes specific recommendations based on research conducted in 2012 by African Population and Health Research Center in collaboration with the Ministry of Health among other local and international partners.

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Background:

Of world’s estimated 19 million induced abortions, about 6 million of these are in Africa alone, where in most countries, abortion is still illegal [5, 7-9]. Unplanned pregnancies are a leading cause of induced abortion [10, 11]. Improved access to effective contraception would reduce the number of unplanned pregnancies, and consequently the number of would-be unsafe abortion [10, 12, 13] while adherence to quality standards [14, 15] assure better outcomes [7, 16].

Inadequate health care resources and infrastructure, restrictive laws and policies and stigma  contributed to  abortion-related mortalities[8, 15]. Properly performed Quality post abortion care (PAC) procedures can substantially prevent most of maternal morbidities and mortalities [8, 17, 18]. These entail improved access to high-quality comprehensive care, community-provider partnerships, counselling, timely treatment of incomplete abortions, contraceptive and family planning services, and other reproductive health services [19, 20] at all levels.

Methodology:

The study on which this brief is based used a mix of qualitative and quantitative methodologies to provide estimates of induced abortion rates using the indirect abortion incidence complications methodology and the direct abortion morbidity methodology to estimate levels of complications from unsafe abortions in Kenya. The study used a nationally representative sample of both private and public facilities in all regions in Kenya, cutting across level II through level VI.   The qualitative data provides evidence on some of the motivations to induced abortions and seeking remedy in healthcare facilities as well as choice of these facilities.

Problem description:                                           

The current policy on management of post abortion care patients and infrastructural situation around treatment of PAC does not offer a solution to the heightened complications due to delayed contact with qualified healthcare personnel from the onset of complications. Currently, most level II facilities are not expected to provide PAC services. Furthermore, the ministry’s recommended PAC treatment is vacuum aspiration and medical abortion for early gestation PAC while dilation and curettage (D&C) is the recommended surgical procedure for 2nd trimester PAC treatment. However, most MVA/EVA procedures are performed by the clinical officers, medical officers and specialist gynecologists (70%). Interestingly, majority of level II facilities are run by nurses, who offer 75% of digital evacuations, while only a third of all level II facilities reported use of MVA for treatment of PAC patients.

The solution:

The need to involve level II facilities as well as community health workers (CHW) and community health extension workers (CHEWs) in the treatment and detection of complications from unsafe abortion is paramount in addressing the above problem. Training of nurses, nurse aids and CHWs/CHEWs will certainly close this gap and reduce the risk of complications from unsafe abortions.

Kenya has one of the highest abortion rates, currently at 48 abortions per 1000 women of reproductive age, higher than the regional (East Africa) average of 39 per 1000, an increase from 45 per 1000 women in 2002. A comprehensive PAC program in all levels of care will minimize the risk of repeat abortion hence the risk of complications, while emphasizing on more preventive measure such as mandatory post abortion contraception.

The findings from this survey show high levels of both moderate and severe complications (77%) from unsafe abortions. There is further evidence of more severe complications among women who take longest to seek treatment for complications from unsafe abortion. Majority of PAC seekers were more likely to seek medical care more than 12 hours after the onset of first signs of complications. Enabling community health CHWs and CHEWs to detect these complications and level II facilities to not only detect but also treat these cases will reduce this risk drastically. Results from this study further estimates a case fatality of 900 per every 100000 cases treated at healthcare facilities.

Previous evidence on abortion rates in Kenya is based on data that date back in 2002. These new findings are based on nationally representative data collected in 2012. The methodologies used for estimation have also been widely published in peer reviewed journals and have also been used in many other African countries with similar legal and policy frameworks. Similar studies have been implemented elsewhere in African countries that share similar challenges as Kenya and have informed respective governments on need for improved service availability to minimize risks of complications from unsafe abortions. In addition, with the registration of Misoprostol, Mifepristone and soon Medabon in Kenya, medical management of PAC patients which requires minimal skills can be promoted at these lower level facilities.

VI/ Policy recommendations:

There is an urgent need to train, and equip level 2 facilities with MVA and where applicable EVA kits. This should be compounded with promotion of use of Misoprostol for treatment of incomplete and inevitable abortions. These will further avail PAC services at lower service levels and reduce the risks of complications. Failure to do this would mean that the first three levels of contact will continue to offer first aid services and referral for all complicated cases, which further exposes women to severe complication due to delayed treatment. This intervention is likely to reduce the 30% complicated cases that were due to delayed treatment, hence drastically reducing the case fatalities from unsafe abortion.

Call to action:

  • The RMHU to train all Nurses and Nurse aids on MVA/EVA treatment. The department should also provide guidelines that encourage use of recommended treatments and minimal use of non-recommended procedures such as digital evacuation and more expensive and resource demanding procedures such as D&C.
  • The RMHU to develop a training curriculum and plan to train at least 500 CHW in every county on early detection of complications from unsafe abortions as well as the safe use of medical abortion products already in the market
  • The RMHU to establish a referral system by linking CHW to specific level II facilities and the establishment of toll-free telephone communication for CHW to report complications and seek assistance from their contact dispensary.
  • Ministry of medical services to equip all level II and Level III facilities with MVA/EVA kits

 Bibliography:

  1. Kenya Demographic and Health Survey 2008-9, in KNBS and ICF Macro. 2010, KNBS and ICF Macro: Calverton, Maryland.
  2. Prof, D.D.A.G.M., Janie Benson, Susheela Singh, Mariana Romero, Bela Ganatra, Prof Friday E Okonofua and  Iqbal H Shah, Unsafe abortion: the preventable pandemic. The Lancet, 2006. 368(9550): p. 12.
  3. Singh, S., Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries. Lancet, 2006. 368(9550): p. 15.
  4. Gebreselassie, H., Maria F. Gallo, Anthony Monyo and Brooke R. Johnson, The magnitude of abortion complications in Kenya. BJOG: an International Journal of Obstetrics & Gynaecology, 2005. 112(9): p. 16.
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  6. Kenya National Post Abortion Care Curriculum: Trainer’s Manual §§1, 26. 2003, Ministry of Health, Kenya: Kenya.
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  13. Levandowski BA, P.E., Linguzi J, Katengeza HR, Reproductive health characteristics of young Malawian women seeking post-abortion care. African Journal of Reproductive Health / La Revue Africaine de la Santé Reproductive, 2012. 16(2): p. 18.
  14. Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2008. 2011, World Health Organization (WHO): Geneva.
  15. Safe abortion: Technical and policy guidance for health systems. 2012, World Health Organization (WHO): Geneva.
  16. Mitchell, E.M.H., et al., Social Scripts and Stark Realities: Kenyan Adolescents’ Abortion Discourse. Culture, Health & Sexuality, 2006. 8(6): p. 515-528.
  17. Hessini, L., Global Progress in Abortion Advocacy and Policy: An Assessment of the Decade since ICPD. Reproductive Health Matters, 2005. 13(25): p. 88-100.
  18. Commitments to Sexual and Reproductive Health and Rights for All: Framework for Action. 1995, Family Care International: New York.
  19. Better health in Africa: Experience and lessons learned. 1994, World Bank: Washington, D.C.
  20. Banerjee SK, A.K., Warvadeker J., Pathways and consequences of unsafe abortion: a comparison among women with complications after induced and spontaneous abortions in Madhaya Pradesh, India. international journal of Gynecology and Obstetetrics, 2012. 118(Suppl 2): p. 7.
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