PUBLIC HEALTH ASPECTS OF

ABORTION:

AN OVERVIEW

By

Prof F. E. Okonofua
Provost
College of Medical Sciences
University of Benin
Abortion is the loss of pregnancy
before it has reached stability

Two types:
 Spontaneous

 Induced
 Estimates of Abortion
1. Spontaneous Abortion – Estimates are
unknown, because many are non-clinical
abortions

3. Induced Abortion
Developed Countries - 500,000
Developing Countries - 18,400,000
Total (World) - 19 million
Africa - 4.2 million
Nigeria - 610,000
 Impact of induced Abortion
Number of % of all
maternal deaths maternal
deaths
From Abortion

World 67,900 13
Developed countries 300 14
Developing Countries 67,500 13
Africa 29,800 12
Nigeria *20,000
40*
 Clinical Aspects of
Spontaneous Abortion
Spontaneous Abortion

Threatened Abortion Inevitable Abortion

(including belighted ovum and missed
abortion)

Incomplete Abortion Complete Abortion

 Threatened Abortion
 Mild to moderate vaginal bleeding
 Uneffaced and undilated cervix
 No abdominal pain
 Fetus often viable
 Conservative management
 Inevitable Abortion

1. Blighted ovum
2. Severe effacement and dilatation of
the cervix, with or without passage
of products of conception
3. Death and retention of the fetus
between 12 and 28 weeks (missed
abortion)
 Treatment of Inevitable
Abortion
1. D&C versus MVA

2. Misoprostol
- all stages, including blighted
ovum
 Aetiology of Recurrent
Abortion
1. Cervical Incompetence
2. Maternal illnesses – hypo or
hyperthyroidism diabetes mellitus,
cardiovascular diseases
3. Materno-fetal infections (toxoplasmosis,
Listeria monocytogene, rubella,
cytomegalovirus, herpes simplex virus,
brucella, Chlamydia, ureaplasma
urealyticum, T-strain mycoplasma)
4. Endocrine factors – polycystic ovarian
disease, luteal phase defect
5. Chromosomal anomalies
6. Immunological incompatibility
 Investigation of Recurrent
Abortion
1. Detailed History and physical examination
2. Hormone Assay
3. Thyroid, renal & liver function tests
4. Glucose tolerance tests
5. HSG
6. Ultrasound scan
7. SLE Lupus anti-coagulant test
8. Anti-cardiolipin antibodies
9. Anti-nuclear factor
10. Anti-thyroid antibodies
11. Blood grouping
12. HLA typing in both partners
 Treatment of Recurrent
Abortion
 Treatment of underlying medical
conditions
 Progesterone vaginal pressaries
 Myomectomy
 Cervical cerclage
- Lash & Lash procedure
- Shirodkar’s technique
- MacDonald's technique
 Induced Abortion
 Induced Abortion is done in all societies
and in all cultures
 The issues is whether it is safe or unsafe
 Induced abortion tends to be safe in
countries where abortion is legal and
unsafe in countries where abortion is
restrictive and legal
 Abortion tends to be safe in developed
countries and unsafe in developing
countries
 Patterns of Abortion Law in
Africa Countries
No of Countries
2. Abortion to save life of
pregnant woman only 24
4. Abortion to preserve the life or health of a woman
9
5. To save her life and in cases of rape
2
6. To preserve her life or health in cases of
contraceptive failure
1
8. In cases of pregnancy resulting from rape and
incest – and fetal defect & to preserve her life & health
9
6. Additional indication of socioeconomic hardship
(Zambia) 1
12. Additional indication of a woman who is too young or
mentally unable to care for a child (Ethiopia)
1
14 On request (Cape Verde, South Africa & Tunisia) 3

TOTAL 53
 Why Women have Unwanted
Pregnancy and Seek Abortion
 They are too young or want postpone
child bearing
 They want no more children
 They cannot afford to raise a child
 They are unmarried or still in school
 Their partners does not want the
pregnancy or there is a problem with
relationship
 They become pregnant due to rape or
incest
 Determinants of unwanted
Pregnancy and Unsafe Abortion
 Young maternal age
 The role of women education
 Pattern of contraceptive use
 Religion
 Abortion laws
 Provider attitude and training
 Use of outdated abortion methods and
technology
 Economic and geographic inequality
 Complications of Induced
Abortion
 Immediate
- Occurring during or within 48
hours
 Late
- Occurring later, especially
after 48 hours
Early Complications of Induced
Abortion
 Haemorrhage
 Damage to adjacent organs –
perforated uterus
 Sepsis (Septic abortion)
- Gram negative septicaemia
 Treatment of Early
Complications of Induced
Abortion
1. Intravenous infusion and/or blood
transfusion
2. Blood spectrum antibiotics
3. Evacuation of retained products of
conception (MVA)
4. Laparotomy
 Late complications of induced
Abortion
1. Chronic pelvic inflammatory disease
2. Ectopic pregnancy
3. Cervical Incompetence
4. Asherman syndrome
 Regimen for Safe Practice of
Abortion
A 1st seven weeks
 Mifepristone – misoprostol
 Misoprosotol alone
 MVA
 D&C

B 8 – 14 weeks
 Misoprostol – MVA
 Misoprostol – D & C

C After 14 weeks
 Mifepristone – misoprostol
 Repeated doses of misoprostol
 Different Perspectives of
Abortion
 Abortion - a public health issue
 Abortion - a gender issue
 Abortion - a rights issue
- right to life
- right to health, reproductive
health and family planning
- right to be free from
discrimination
- right to liberty & security of
persons
- right to scientific progress
 Abortion - a social and economic justice
issue
 Prevention of Unsafe
A
Abortion
Primary Prevention
- sexuality education
- promotion of contraception
B Secondary Prevention
- provision of counseling to women with
unwanted pregnancies
- Liberation of abortion laws
- Increasing women’s access to safe abortion
services
C Tertiary Prevention
- Post abortion Care (PAC) at all levels
- In-services and pre-service training of
providers
- Decentralization of PAC
Thank you