Overview of abortion cases with severe maternal outcomes in the WHO Multicountry Survey on Maternal and Newborn Health: a descriptive analysis

Authors


Abstract

Objective

To summarise individual and institutional characteristics of abortion-related severe maternal outcomes reported at health facilities.

Design

Secondary analysis of data from the WHO Multicountry Survey on Maternal and Newborn Health.

Setting

85 health facilities in 23 countries.

Sample

322 women with abortion-related severe maternal outcomes.

Methods

Frequency distributions and comparisons of differences in characteristics between cases of maternal near miss and death using Fisher's exact tests of association.

Main outcome measures

Individual and institutional characteristics and frequencies of potentially life-threatening conditions, and interventions provided to women with severe maternal outcomes, maternal near miss, and maternal death.

Results

Most women with abortion-related severe maternal outcomes (SMOs) were 20–34 years old (65.2%), married or cohabitating (92.3%), parous (84.2%), and presented with abortions resulting from pregnancies at less than 14 weeks of gestation (67.1%). The women who died were younger, more frequently without a partner, and had abortions at ≥14 weeks of gestation, compared with women with maternal near miss (MNM). Curettage was the most common mode of uterine evacuation. The provision of blood products and therapeutic antibiotics were the most common other interventions recorded for all women with abortion-related SMOs; those who died more frequently had antibiotics, laparotomy, and hysterectomy, compared with women with MNM. Although haemorrhage was the most common cause of abortion-related SMO, infection (alone and in combination with haemorrhage) was the most common cause of death.

Conclusion

This analysis affirms a number of previously observed characteristics of women with abortion-related severe morbidity and mortality, despite the fact that facility-based data on abortion-related SMO suffers a number of limitations.

Introduction

Unsafe abortion is defined by the World Health Organization (WHO) as a procedure for terminating an unintended pregnancy carried out by persons lacking the necessary skills or in an environment that does not conform to minimum medical standards, or both.[1] According to the most recent WHO estimates in 2008, unsafe abortion accounts for 13% of maternal mortality worldwide, and an estimated 5 million women are admitted to hospital with complications from unsafe abortion each year.[2] In settings where safe abortion is widely available, procedure-related complications are rare. In contrast, when access to safe abortion is limited, there is a much higher incidence of abortion-related morbidity and mortality.[3, 4]

The challenges of collecting accurate information about the incidence of abortion and its associated morbidity and mortality are well documented.[5-7] This is particularly the case in settings with legally restrictive abortion policies, where women are more likely to undergo clandestine, unsafe abortions that bypass formal medical systems, resulting in serious procedure-related complications. Many women may also avoid seeking care for complications because of sociocultural stigma, fear of legal consequences, and financial costs, sometimes dying before ever making it to a health facility. Among women who do present to facilities for treatment, some may not disclose the underlying cause of their complication to healthcare providers. This behaviour can impede timely recognition and treatment, and can also hinder any data collection efforts. Moreover, healthcare providers may be reluctant to report abortion-related morbidity and mortality because of fear of stigma and legal retaliation against their patients and themselves. As a result, facility-based data on abortion—especially in legally restrictive settings—are often not an accurate reflection of the true toll of abortion-related morbidity and mortality in a population.

The WHO Multicountry Survey (WHOMCS) recorded data on women with severe maternal outcomes related to abortion who sought care at participating health facilities.[8] The objective of this analysis is to describe the characteristics of these women and the facilities that provided them with care, as well as the interventions they received and their health conditions and outcomes.

Methods

This secondary analysis was based on cross-sectional data from the WHOMCS on Maternal and Newborn Health. Data were collected on 314 623 women who received pregnancy-related care in 359 facilities across 29 countries. Although the vast majority of women in this survey were admitted for delivery, data were also collected on a small subset of women with severe maternal outcomes (SMOs) related to abortion. Data collection took place between 1 May 2010 and 31 December 2011; facilities eligible for inclusion conducted over 1000 deliveries per year and had the capacity to perform caesarean delivery. Detailed methods for the study's implementation have been published previously.[9]

The secondary analysis included all women coded as having an abortion and who had severe maternal outcomes. The database did not specify whether abortion was induced or spontaneous. The SMOs included maternal deaths (MDs) and maternal near misses (MNMs) (MD + MNM = SMO). A maternal near miss was defined as a woman with a life-threatening condition, with evidence of organ dysfunction, at the time of admission or during her hospital stay.[10]

Using the United Nations Division of Population's World Abortion Policies (2011), we classified the legal environments surrounding abortion provision as very restrictive, restrictive, or least restrictive.[11] Very restrictive settings either prohibit legal abortion altogether or allow it only in the instance of saving a woman's life. Restrictive settings permit abortion in any of the following circumstances, in addition to saving a woman's life: to preserve a woman's physical or mental health; rape or incest; or fetal impairment. Countries designated as least restrictive provide legal abortion for any of the previously mentioned conditions as well as for social or economic reasons, or on request.

Local data collectors undertook daily surveillance of obstetrical, postpartum wards, gynaecological or abortion units, delivery rooms, and emergency and intensive care units to identify eligible women with severe maternal outcomes as part of standard study procedures. Information about women presenting to facilities for uncomplicated abortions or less severe complications of abortion was not collected. Data were abstracted from hospital records at the time of discharge, transfer, or death, recorded on paper forms, and later entered into a web-based data management system, either by staff at the facility or at a central level, depending on the available resources and infrastructure.

All statistical analyses were conducted using stata 11 (Statacorp, College Station, TX, USA). We document the women's sociodemographic and obstetrical characteristics, as well as the facility characteristics, for all reported cases with SMO associated with abortion. Additionally, we show the frequency of abortion-related conditions (including infection and haemorrhage) and evidence of organ dysfunction with the frequency of interventions provided to women with these conditions. We present frequency distributions for descriptive statistics, and Fisher's exact tests of association were used to evaluate differences between groups.

Results

During the study period, a total of 322 cases of SMO associated with abortion were reported at 85 hospitals (23% of all WHOMCS facilities), representing 23 countries. Far fewer cases than expected were reported, probably resulting in part from the varying degrees of rigour applied to surveillance for abortion-related SMO across sites. Table 1 presents the distribution of abortion-related SMO cases by country as well as the distribution of all cases included in the main WHOMCS, categorised according to the legal status of abortion. About half of the sample (52.1%) was derived from very restrictive settings; specifically, Afghanistan contributed 134 cases or 41.9% of the total severe maternal outcomes associated with abortion considered in this analysis.

Table 1. The distribution of abortion-related cases with severe maternal outcomes (SMOs) by country and legal status of abortion
 All abortion SMOs n = 322All women in WHOMCS n = 314 623
  1. Data are n (%). Restrictive categories were derived from the UN, Department of Economics and Social Affairs, Population Division[11] (www.un.org/esa/population/publications/2011abortion/2011abortionwallchart.html)

  2. a

    Although the country of Mexico has very restrictive laws regulating abortion, reporting facilities included sites in the Distrito Federal, Mexico City, where abortion regulation meets the criteria for least restrictive.

Very restrictive
Afghanistan135 (41.9)26 148 (8.3)
Angola4 (1.2)10 450 (3.3)
Democratic Republic of Congo15 (4.7)8756 (2.8)
Lebanon0 (0)4044 (1.3)
Nicaragua7 (2.2)6571 (2.1)
Mexicoa1 (0.3)6648 (2.1)
Occupied Palestinian Territory0 (0)980 (0.3)
Paraguay2 (0.6)3610 (1.2)
Phillipines3 (0.9)10 783 (3.4)
Sri Lanka1 (0.3)18 129 (5.8)
Subtotal168 (52.1)96 119 (30.6)
Restrictive
Argentina4 (1.2)9807 (3.1)
Brazil2 (0.6)7058 (2.2)
Ecuador4 (1.2)10 245 (3.3)
Jordan0 (0)1167 (0.4)
Kenya5 (1.6)20 354 (6.5)
Niger25 (7.8)11 116 (3.5)
Nigeria11 (3.4)12 841 (4.1)
Pakistan1 (0.3)13 175 (4.2)
Peru16 (4.9)15 285 (4.9)
Qatar0 (0)3950 (1.3)
Thailand8 (2.5)8973 (2.9)
Uganda46 (14.3)10 923 (0.3)
Subtotal122 (37.9)124 894 (39.7)
Least restrictive
Cambodia2 (0.6)4725 (1.5)
China0 (0)13 277 (4.2)
India11 (3.4)31 318 (10.0)
Japan0 (0)3537 (1.1)
Mongolia5 (1.6)7365 (2.3)
Distrito Federal, Mexico Citya3 (0.9)6814 (2.2)
Nepal10 (3.1)11 290 (3.6)
Vietnam1 (0.3)15 437 (4.9)
Subtotal32 (9.9)93 763 (29.8)

Tables 2 and 3 compare the characteristics of women with abortion-related MNM and MD. Women who presented to facilities with SMO were most frequently between the ages of 20 and 34 years, were married or cohabitating, and reported little to no education. Also, most women had previously given birth and experienced their index abortion prior to 14 weeks of gestation. Twenty-seven women died, translating to a case fatality rate of 83 deaths per 1000 women with SMOs associated with abortion in this sample. Generally, the women who died were younger and single, but shared similarities regarding educational status and parity compared with women with maternal near miss. There were more deaths among women with abortions at ≥14 weeks of gestation compared with women with abortions reported in the first trimester (56.5 versus 43.5%, P = 0.02).

Table 2. Individual, institutional, and country characteristics of abortion cases with severe maternal outcomes (SMOs)
 All abortion SMOs n = 322MNMs n = 295MDs n = 27 P
  1. Data are n (%).

Individual
Age
<20 years24 (7.5)20 (6.8)4 (14.8)0.05
20–34 years210 (65.2)190 (64.4)20 (74.1)
≥35 years88 (27.3)85 (28.8)3 (11.1)
Marital status
Single/separated/divorced/widowed24 (7.7)17 (6.0)7 (26.9)0.002
Married/cohabitating287 (92.3)268 (94.0)19 (73.1)
Education
0124 (38.5)118 (40)6 (22.2)0.38
1–6 years43 (13.4)38 (12.9)5 (18.5)
7–9 years50 (15.5)45 (15.3)5 (18.5)
10–12 years37 (11.5)33 (11.2)4 (14.8)
>12 years68 (21.1)61 (20.7)7 (25.9)
Parity
051 (15.8)43 (14.6)8 (29.6)0.06
1–3148 (45.9)135 (45.8)13 (48.2)
>3123 (38.2)117 (39.7)6 (22.2)
Gestational age (n = 295)
<14 weeks198 (67.1)188 (69.1)10 (43.5)0.02
≥14 weeks97 (32.9)84 (30.9)13 (56.5)
Institutional
Facility location (n = 288)
Urban255 (88.5)234 (89.0)21 (84.0)0.04
Peri-urban9 (3.1)6 (2.3)3 (12.0)
Rural24 (8.3)23 (8.7)1 (4.0)
Level of service (n = 287)
Primary12 (4.2)12 (4.6)12 (4.2)0.001
Secondary44 (15.3)34 (12.9)44 (15.3)
Tertiary89 (31.0)79 (30.2)89 (31.0)
Other referral level142 (49.5)137 (52.3)142 (49.5)
Maternity-exclusive facility (n = 286)
Yes36 (12.6)35 (13.4)36 (12.6)0.16
No250 (87.4)226 (86.6)250 (87.4)
Facility Capacity (n = 275)
All essential services offered222 (80.7)204 (80.3)222 (80.7)0.29
All essential services not offered53 (19.3)50 (19.7)53 (19.3)
Country
Human Development Index Group
Very High/High31 (9.6)29 (9.8)2 (7.4)0.70
Medium/Low291 (90.4)266 (90.2)25 (92.6)
Legal status of abortion
Very restrictive168 (52.1)156 (52.8)12 (44.4)0.28
Restrictive122 (37.9)112 (37.9)10 (37.0)
Least restrictive32 (9.9)27 (9.3)5 (18.6)
Table 3. Interventions provided for abortion cases with severe maternal outcomes (SMOs)
 All abortion SMOs n = 322MNMs n = 295MDs n = 27 P
  1. Data are n (%).

Type of abortion procedure
Curettage193 (59.9)179 (60.7)14 (51.8)0.02
Vacuum aspiration65 (20.2)61 (20.7)4 (14.8)
Medical21 (6.5)21 (7.1)0 (0)
Removal of retained tissue, method unspecified12 (3.7)10 (3.4)2 (7.4)
No reported procedure31 (9.6)24 (8.1)7 (25.9)
Other interventions provided
Therapeutic antibiotics92 (28.7)77 (26.2)15 (55.6)0.001
Blood products234 (81.3)212 (80.6)22 (88.0)0.59
Massive transfusion44 (13.7)40 (13.6)4 (14.8)0.77
Laparotomy18 (5.6)11 (3.7)7 (25.9)0.001
Hysterectomy20 (6.2)14 (4.8)6 (22.2)0.003
Frequency of potentially life-threatening disorders
Abortion-related haemorrhage226 (70.2)219 (74.2)7 (25.9)<0.001
Abortion-related infection25 (7.8)11 (3.7)14 (51.8)
Abortion-related haemorrhage and infection25 (7.8)21 (7.1))4 (14.8)
Other medical disease34 (10.6)34 (11.5)0 (0)
No reported condition12 (3.7)10 (3.4)2 (7.4)
Organ dysfunction in first 24 hour
Yes183 (56.8)165 (55.9)18 (66.7)0.32
No139 (43.2)130 (44.1)9 (33.3)
Referred from other health facility
Yes77 (23.9)66 (22.4)11 (40.7)0.05
No245 (76.1)229 (77.6)16 (59.3)

Cases of abortion-related SMO were most common in countries with medium and low Human Development Index (HDI) groups, as well as in very restrictive and restrictive legal environments regulating abortion.[12] Most of the women in this sample sought treatment at urban, non-maternity-exclusive hospitals. The capacity of the facility and the availability of essential services reflect a composite variable of basic building capacity, general medical services, emergency obstetric services, laboratory testing, hospital practices, and human resources.[13] A majority of women with SMO were reported from sites with all essential services. Nearly one-quarter of the women were transferred from other facilities for care: 40.9% of these women died.

Overall, most women underwent abortion management with curettage. Abortion-related haemorrhage was the most common condition noted among women with MNM, whereas abortion-related infection was the most common condition recorded for women with MD. Overall, blood transfusion was the most common intervention provided. Women who died more frequently had antibiotics, laparotomy, and hysterectomy, compared with those with MNM. Of all reported organ dysfunctions, cardiovascular dysfunction was most common (80.1%). Fifty-one percent of all abortion-related deaths occurred within 24 hours of admission to the facility.

Table 4 evaluates the frequency of abortion procedures provided across settings with various degrees of restriction to abortion. Sharp curettage was the predominant method for abortion or completion of abortion across all countries and levels of restriction, although its use was most common in very restrictive and restrictive settings. In settings with greater access to safe abortion, there was a trend towards an increased use of vacuum aspiration.

Table 4. Distribution of abortion method provided, according to legal status of abortion
 Very restrictive n = 168Restrictive n = 122Least restrictive n = 32
  1. Data are n (%).

Type of abortion procedure
Curettage119 (70.8)59 (48.3)15 (46.8)
Vacuum aspiration25 (14.9)27 (22.1)13 (40.6)
Medical14 (8.3)5 (4.1)2 (6.3)
Removal of retained tissue, method unspecified4 (2.4)8 (6.6)0 (0)
No reported procedure6 (3.6)23 (18.9)2 (6.3)

Discussion

Main findings

The profiles of women with severe abortion-related maternal outcomes in the sample (age, partnership status, level of education, parity, and gestational age) are similar to the characteristics of women reported in several studies based on national data.[14, 15] Comparisons between characteristics of MNM and MD also affirm previous research findings. Young women (<20 years of age), single women, and women undergoing abortions at later gestational ages died at a higher frequency than those who survived; other studies demonstrate that these characteristics are associated with an increased risk for death after abortion.[16, 17] Given that the burden of maternal mortality and morbidity related to abortion is greatest in legally restricted settings, it is not surprising that the majority of cases in this data set were from countries in which abortion was either restrictive or very restrictive. Additionally, the highest burden of abortion-related SMOs was seen in low- or medium-HDI countries. This is also consistent with prior research, which indicates that almost all abortion-related deaths occur in developing countries.[18]

Haemorrhage and infection are common complications associated with abortion. In this analysis, the most frequent cause of all potentially life-threatening conditions was haemorrhage; however, infection was the leading cause of death. Previous studies have described sepsis as the main cause of abortion-related death worldwide, particularly in the setting of unsafe abortion.[16]

We noted the prevalent use of sharp curettage, especially in very restrictive settings. This finding could be a reflection of country-level practices, particularly in Afghanistan, but it also suggests a need for provider training in evidence-based surgical and medical evacuation techniques. The WHO recommends that all efforts should be made to replace curettage with vacuum aspiration and medical methods for safe abortion.[19] With regard to surgical methods, copious evidence suggests that vacuum aspiration is more effective than curettage, is safer, and is also cost-saving for health systems.[20-22]

Strengths and limitations

Although instructions were provided for the identification of women admitted to non-obstetrical wards in hospitals, the rigour with which abortion cases were ascertained varied among reporting facilities, as severe abortion-related morbidity and mortality was not the primary focus of the WHOMCS. We observed a high proportion of severe abortion-related maternal outcomes in Afghanistan and Uganda, whereas facilities in six countries reported none and facilities in 13 countries reported five or fewer cases during the data collection period. Based on what is known from global and regional estimates of severe morbidity and mortality associated with abortion, particularly in areas where unsafe abortion is prevalent, it is apparent that this study failed to capture all abortion-related morbidity and mortality, in particular women who may have died at the community level before ever making it to a facility.[2] There is a high burden of unsafe abortion both in Afghanistan and in Uganda that could account for our observations in these countries; however, a more likely explanation for the variation and small numbers of reported cases across countries is disproportionate facility reporting arising from the challenges of collecting accurate data relating to abortion. The recent attention to abortion-related morbidity and mortality in these two countries may also have led to a greater interest and willingness of these providers to record abortion-related data.

Women with abortion were not distinguished by the circumstance of their pregnancy termination (spontaneous versus induced abortion). Spontaneous and induced abortion share many similar clinical signs and symptoms, and in settings where unsafe abortion is prevalent, women seeking treatment for complications in facilities may report a miscarriage, despite actually undergoing abortion. Combining these entities to evaluate severe abortion-related morbidity and mortality is not uncommon.[6]

We present data on the reported abortion procedure associated with each case; however, these categories are susceptible to misclassification. Data collectors coded the final mode of termination corresponding to either the method of abortion or the completion of abortion. It is not possible to distinguish between miscarriage and abortions in this sample, and we cannot delineate between the method by which the abortion was initiated (and which led to a complication) and the subsequent interventions that may have been provided as part of emergency treatment for incomplete abortion.

It is also not possible to determine the proportion of complications attributable to safe or unsafe abortion. We observed that among all women with severe abortion-related outcomes, stratified by legal setting, the least restrictive legal settings reported the highest proportion of deaths. This may not be so surprising considering that many women who suffer abortion-related severe complications in more restrictive settings never make it to a facility for care, thereby leading to an underestimation abortion-related MNMs and MDs in these countries. On the other hand, even in less restrictive settings safe abortion services may not always be available, and complications and morbidity may still be common. For example, all deaths originating from the least restrictive settings in the sample occurred in India, where liberal laws exist, but where access to safe abortion services remains a problem.[16]

Finally, as with any facility-based data set, this analysis does not provide population-representative characteristics of women with severe abortion-related MNM and MD. No generalisations can be extrapolated to represent all women with severe abortion-related morbidity and mortality. Despite its significant limitations, this is one of very few studies to apply standardised criteria for defining potentially life-threatening conditions, and evidence of organ dysfunction, to characterise abortion-related MNM and MD among women seeking facility-based care for complications.23

Interpretation

Given the large number of women included in the survey and the numerous participating facilities, the number of reported cases that were documented as an abortion-related SMO is quite small. This finding is surprising given what is known about the relatively large contribution of abortion-related complications to maternal mortality and morbidity in many of the settings in which the survey was conducted.[2]

The sample reflects the limitations of facility-based data to accurately collect information about abortion, including disparate under-reporting and misclassification, as noted earlier. The interpretation of these results must take into account that many of these same settings are also places where abortion is legally restricted. Importantly, it must also be recognised that many women who suffer severe abortion-related complications, particularly in restrictive areas, do not present to facilities for care. These results should not be taken to be representative of the global burden of abortion-related morbidity and mortality.

Conclusion

The findings of this study reflect the characteristics of the women, facilities, and country contexts affected by the majority of severe abortion-related morbidity and mortality, where unintended pregnancy, unsafe abortion, and limited health resources prevail. Even in settings with less restrictive abortion regulations, inadequate access to safe abortion services may influence the frequency of abortion-related complications. Additionally, this analysis highlights a need for training in evidence-based abortion services, vacuum aspiration, and medical methods, particularly in restrictive settings, given the frequent use of curettage. It is essential to recognise that most morbidity and mortality associated with abortion is preventable by reducing unintended pregnancy and by increasing access to, and strengthening the ability of health systems to provide, safe abortion services.

Disclosure of interests

The authors declare that we have no conflicts of interest to disclose.

Contribution to authorship

All authors (MD, BG, WS, ZQ, JB, BW) participated in the conception and planning of this article, and in the interpretation of the results. MD performed the data analysis and drafted the article. All authors reviewed the article and provided input to the final version. The final responsibility for the decision to submit the article for publication was shared among the group.

Details of ethics approval

The HRP Specialist Panel on Epidemiological Research reviewed and approved the study protocol for technical content. This study was approved by the WHO Ethical Review Committee and the relevant ethical clearance mechanisms in all countries (protocol ID A65661; 27 October 2009).

Funding

The original survey was financially supported by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Training in Human Reproduction (HRP); World Health Organization (WHO); United States Agency for International Development (USAID); Ministry of Health, Labour and Welfare of Japan; and Gynuity Health Projects.

Acknowledgements

The authors wish to thank all members of the WHO Multicountry Survey on Maternal and Newborn Health Research Network, including regional and country coordinators, data collection coordinators, facility coordinators, data collectors, and all staff at participating facilities, who made the survey possible.

Ancillary