Abortion‐related infections across 11 countries in Sub‐Saharan Africa: Prevalence, severity, and management

To estimate the prevalence of infection among abortion‐related complications in health facilities, describe their management, and identify sociodemographic and clinical factors associated with abortion‐related infections.


| INTRODUC TI ON
In Sub-Saharan Africa, 75.6% of abortions are considered unsafe. 1,2 Although unsafe abortions are more prone to complications, these can also arise from spontaneous or induced safe abortion. Abortionrelated complications account for nearly 10% of maternal deaths in Africa. 3 They usually include infections, hemorrhage, uterine perforation, and injuries. 4,5 A global facility-based study found that postabortion infection represents 9.5% of the global burden of maternal infections and 22.1% of complicated maternal infections. 6 Previous studies have been published on abortion-related severe maternal outcomes. For instance, in a cross-sectional study conducted in three provinces in Zambia, Owolabi et al. 7 reported that 10% of near-miss cases had a septic shock. A hospital-based cross-sectional study in Central and Eastern Uganda also found that 16% of the severe cases had an infection. 8 Furthermore, a study that included countries from Latin America, Asia, and Africa-with different levels of restriction in abortion-related laws and policies-found that infection was involved in 15.6% (7.8% infection and 7.8% infection and hemorrhage) of abortion-related severe maternal outcomes and 66.6% (for infection only or associated with hemorrhage) of abortion-related maternal deaths.
Overall, according to the pooled estimate, infection was the most common cause of abortion-related maternal death. 9 Although there are studies already published, the current body of evidence on postabortion maternal near miss and deaths in Sub-Saharan Africa is from a limited number of countries and used various designs or definitions of the concepts. The present study will contribute to improve the evidence to inform adequate management of postabortion infection.
The lack of evidence on abortion morbidity and mortality in Sub-Saharan Africa is due to measurement challenges related to reporting bias, stigma, and restrictive laws and policies in most countries. 10 In addition, there is a need for standardization of the definitions used in the studies to assess the burden of abortion-related infections. 11 The present analysis sought to contribute to bridging these gaps, especially in Sub-Saharan Africa, because previous studies have shown that complications, mainly infections, are more frequent in settings where access to abortion services is restricted. 2,12,13 Consequently, the availability of Sub-Saharan Africa-specific data can improve the body of evidence on the burden of abortion-related infections in these settings where restrictive laws and policies do not facilitate reliable data collection. 2,14 The aim of the present study was to estimate the prevalence of infections among abortion-related complications, identify factors associated with abortion-related infections, and describe the management using the World Health Organization Multi-Country Study on Abortion-related morbidity (MCS-A) dataset.

| MATERIAL S AND ME THODS
We carried out a secondary analysis of the MCS-A, a cross-sectional sur- Data on women seeking care for abortion-related complications (sociodemographic data, clinical information, obstetrics characteristics, signs and symptoms due to abortion-related complication, medical procedures, clinical outcomes, and vital status at discharge) including ectopic and molar pregnancies at the time of facility admission were abstracted from medical records, which were then entered into a web-based platform by research assistants at each facility. The procedures of the study are explained in more detail elsewhere. 15 For the current analysis, only women with abortion-related complications were included. All participants were categorized into three groups, based on the levels of severity of the complications: severe maternal outcome (maternal deaths and near miss per the WHO definition), 16,17 potentially life-threatening condition (severe hemorrhage, systemic infection, or uterine perforation), and moderate complications (bleeding, suspected intra-abdominal injury, and infection). 15 Women were classified based on their infection status within the severity categories. For moderate complications, infections were defined based on chills, fever, sweat, or a foul-smelling vaginal discharge with no life-threatening condition. For potentially life-threatening conditions, infections were based on the presence of systemic infection, which was defined in this study as fever, confirmed or suspected infection (septic abortion or endometritis), new/ worsened altered mentation, respiratory rate of 22 or above, and systolic blood pressure less than or equal to 100.
Mild cases are presented in Annex IX of the paper by Qureshi et al.. 15 They were excluded from this analysis because they did not include infections or any of the other complications (they were based on abnormal signs from an initial physical examination). 15 Abortion-related infections among women in the group of severe maternal outcomes were based on any of the infection signs or symptoms described above and death or the WHO criteria of near miss (cardiovascular, respiratory, renal, coagulation, hepatic, neurologic, or uterine dysfunction). 15 Our outcome of interest in this study was the presence of infec-  For management-related variables, we first computed a variable treatment with mutually exclusive categories to assess the utilization of therapeutic antibiotics, uterotonics, and uterine evacuation. The different categories were antibiotic only, uterotonic and antibiotic, uterine evacuation, antibiotics, all three, and other procedures. In addition, the following variables were coded as "yes" or "no": transfusion of blood products, hysterectomy, exploratory laparotomy, and intensive care unit (ICU) admission.
We used descriptive statistics (percentages) to explore sociode- The protocol of the MCS-A was submitted to and approved by the WHO Ethical Review Committee. Each participating country also obtained ethical approval from their national or institutional review board before the start of the study.

| RE SULTS
We analyzed data for 9232 women with abortion-related complica- The distribution by severity level presented in Figure 1 shows  (Table 2).

| DISCUSS ION
Overall, we found that one in 10 women presenting at facilities with abortion-related complications had an infection. The more severe the complication, the more likely the diagnosis of infec- The pregnancy that ended after the abortion is counted as a previous pregnancy.   Ensuring comparability through the adoption of standard measurement seems essential.
In terms of management, we noted that dilatation and curet-  age of 13 weeks or more, and not living in a couple were more likely to have abortion-related infections. This finding is similar to sociodemographic and clinical risk factors described in studies on abortion-related complications overall. 14,15 Previous studies have also reported inequities about unsafe abortions and highlighted that adolescents and the poorest women were more likely to face them. 14 We hypothesize that vulnerable women may be more at risk of unsafe methods resulting in abortion-related infections due to potential delayed access to postabortion care services. Further research is needed to better understand determinants of delayed access to postabortion care services. There is also a need to explore the quality and outcome of the management of postabortion sepsis.
This study provides information on the prevalence, severity, and management of abortion-related infections in Sub-Saharan Africa using a large sample across 11 countries. However, our study has some limitations. Firstly, this was a cross-sectional facility-based study, which limits the generalizability of our findings at the population and community levels. Due to the retrospective nature of data collection and extracting information from medical records, the study could not specify whether infections occurred after or before a specific type of management. Furthermore, we relied on routine procedures to diagnose infections and other complications.
The differences in the clinical practices could have introduced biases in classifying the participants in the severity and infection groups.
Finally, the information on whether the abortion was spontaneous or induced and the variable on the methods used for induced abortions were not used in this study. Women's self-reports on abortion to healthcare providers, as captured from medical records, are not reliable in a restrictive context where women may be reluctant to report an induced abortion.
While our results indicate that infection is not the leading complication, it is frequent among severe postabortion complications, and has a higher case fatality rate than other complications. In addition, therapeutic antibiotics appeared to be used for women without infection. These findings indicate a need to improve the prevention, early detection, and management of women with abortion-related infections in health facilities via evidence-based practices.

CO N FLI C T O F I NTE R E S T
AB received funding from the HRP Alliance to complete his PhD.
Other authors declare no conflicts of interest.