De Lara, Alyanna Pauline L.

2BSN-2AA-0

Topic: FEMINISTS VIEW ON ABORTION REVIEW OF RELATED LITERATURE: Limited access to contraceptives for all groups of women has been clearly identified as a determinant of unwanted pregnancy and subsequently, induced and even spontaneous abortion in some studies. The issues of accessibility and unmet demand for family planning services is felt more keenly, but is certainly not unique to special populations like adolescents or young unmarried women. These studies also provide compelling evidence that, not only lack of access to reproductive health services but also lack of knowledge and misconceptions about contraceptive methods lead to unwanted pregnancy. Drawing attention to the unmet demand for family planning methods among all groups is essential in reducing unwanted pregnancy and decreasing abortions. In one review of maternal deaths conducted by a Maternal Mortality Review Committee, avoidable factors were found in 92% of the cases. Many of these deaths were attributed to poor post-abortion and delivery management. New studies of clinical management and procedural problems may cause us to review clinical protocols and case management of women suffering from incomplete abortions. Improvements in the clinical management of post-abortion complications can help develop nation-wide standards for a quality of care framework for the treatment of postabortion patients. This literature review highlights problems particular to adolescents that cant be ignored. In one survey of 15-24 year-olds in Addis Ababa, half of the 976 young women interviewed reported having been pregnant and 76% of these women told interviewers that they had a spontaneous (2%) or an induced abortion (74%). Another unpublished thesis proved this finding not uncommon, among 1663 young women interviewed; almost 70% responded that they had an abortion. Another multi-year maternal mortality review conducted at a teaching hospital in Addis Ababa proved the grave outcomes among young women, 14% of the maternal deaths in that study were women under twenty. Access to modern contraceptive methods is still sorely limited for adolescents, perhaps more importantly though, several cross-sectional studies reported inaccurate and low levels of knowledge about modern methods and relatively high levels of knowledge about methods for inducing an abortion. Many of the studies recommended improved sexual health education or family life education and the wider availability of Youth Friendly family planning services in places where young men and women congregate. The importance of these recommendations for the prevention of unwanted pregnancy cannot be overlooked, however, it is also necessary to address issues of legal and induced abortion among young people if we want to save lives. Intervention research that tests the operational effectiveness of new community-based programs and learning instruments will become even more salient in the future.

The outcomes of spontaneous versus induced abortion have been analyzed in many of these studies and have lead to the conclusion that maternal deaths are more often outcomes of induced abortion. Even in studies where the majority of cases were presentations of spontaneous abortions, the majority of deaths were attributable to induced abortions. In a record review of Addis Ababa maternal deaths 35 of 36 abortion-related deaths were induced abortion cases. All of the studies showed more serious complications observed among induced abortion patients. The attitudinal and organizational barriers that impede rapid and high quality abortion care, both from the clinicians as well as the clients perspective, should be explored further in order to have an impact on this outcome. The issue of abortion is undeniably linked to maternal mortality. These studies clearly indicate that the most common cause of maternal death is unsafe abortion. Efforts to improve post-abortion care (PAC) and reduce the presentation of abortion will reduce maternal deaths. National-level data, aggregated retrospective studies, and maternal mortality reviews, amongst other types of studies that can illuminate this correlation should be encouraged. Abortion is linked to violence. Only two of these studies attempted to correlate rape and abortion. In each of these studies rape was cited as the reason for seeking an abortion in 20-25% of the cases. We are left to guess at the actual occurrences of rape and violence that go unreported or do not end in a health institution as a pregnancy or an abortion. Studies and interventions that address gender violence and rape need to elaborate on outcomes of unwanted pregnancy and abortion while attending to the psychosocial needs of the victims. The social impacts of unsafe abortion as a consequence of abduction into marriage and rape need to be examined in our communities. Abortion is common and it should be considered part of a broader reproductive health agenda. Uterine evacuation is one of the most common surgical procedures worldwide. In one crosssectional study reported upon in this review, 21% of a random selection of married women reported a history of abortion. Still, one 5-year review of maternal deaths in a teaching hospital pointed to the finding that 91% of those deaths occurred among un-booked mothers with no history of care before their obstetrical emergency treatment. Interventions and studies that encourage an open and reliable exchange of information and attack the stigmatization of these women can save lives by encouraging early access to information and treatment of incomplete abortion. According to the KAP studies included in this review, the majority of women with a history of abortion are not encountered in the formal health care system while terminating a pregnancy. One KAP study reviewed here indicated that only 16% of women who reported to have had an abortion ever attended a health facility. One study cited that 1/3 of women who confessed to having had an abortion bled for seven days or more. Little work has been done to look at the issue of abortion through womens eyes. More qualitative research that builds a body of work from womens own experiential perspectives is needed. In addition, it is necessary to conduct more community-based descriptive studies that examine the true extent of the problem and the impact on the lives and livelihoods of women and men. Only one urban-based study compared abortion outcomes between rural and urban women. The findings indicated significantly higher hospital stays and higher case-fatality rates for rural

compared to urban women. While almost all levels of health facilities (staffed by all cadres of personnel) acknowledge that they have women presenting with incomplete abortions, the levels of training and preparedness between health facilities and health personnel for post-abortion care vary drastically. Research on the training of mid-level providers and the equipping of lower level health facilities will help to improve womens access to high quality abortion care in all parts of the country and at all levels of health care facilities. Nearly all of the studies illustrated in this review have explored morbidity and mortality outcomes. Post-abortion care is not only traumatic for women and men but also a costly and time-consuming endeavor for health care facilities, providers and families. One hospital-based study reported an average stay of 4 days for abortion admissions, another 6 days for patients suffering from complications of induced abortion. Studies that examine service delivery improvements and new technologies that have an impact on cost and time could promise to have a positive impact in resource-scarce environments. In reading through this literature one cant help but notice the emphasis on special populations such as adolescents. While not undermining the importance of that finding it is still notable that many of these studies indicate significant numbers of married, older, and multiparous women presenting with an induced abortion. Further studies that examine partner involvement in this decision-making process, access to health facilities, unmet need for contraception, and contraceptive failure may enlighten us as to why these women, who might seem to have other options, make this decision to induce an abortion. The legal domain and the social impact of abortion-related issues have not been adequately explored. While this was not a primary objective of this research it should not be overlooked that several of these studies indicated that a number of people feel that abortion should be a personal and private decision. As the Government continues to redefine the penal code, practitioners, researchers and policymakers can work together to inform and evaluate studies on the legal aspects of population and reproductive health. Researchers have a unique opportunity to propose and collaborate on more multi-sectoral research that truly addresses the breadth of this issue as it affects women and men in Ethiopia today. This review illustrates that addressing unsafe abortion is essential in our efforts to reduce maternal mortality and improve reproductive health services for Ethiopians. Research, interventions, advocacy and capacity building that confront the enormity of the problem of unsafe abortion could offer information and solutions that could save thousands of lives.