Best Practice & Research Clinical Obstetrics and Gynaecology

Vol. 22, No. 3, pp. 533–548, 2008

doi:10.1016/j.bpobgyn.2007.10.006
available online at http://www.sciencedirect.com

Maternal mortality and unsafe abortion

Susan R. Fawcus * MA (Oxon.), MBBCH, FRCOG

Associate Professor
Department of Obstetrics and Gynaecology, University of Cape Town, South Africa

Unsafe abortions refer to terminations of unintended pregnancies by persons lacking the nec-
essary skills, or in an environment lacking the minimum medical standards, or both. Globally,
unsafe abortions account for 67,900 maternal deaths annually (13% of total maternal mortality)
and contribute to significant morbidity among women, especially in under-resourced settings.
The determinants of unsafe abortion include restrictive abortion legislation, lack of female
empowerment, poor social support, inadequate contraceptive services and poor health-service
infrastructure. Deaths from unsafe abortion are preventable by addressing the above determi-
nants and by the provision of safe, accessible abortion care. This includes safe medical or surgical
methods for termination of pregnancy and management of incomplete abortion by skilled per-
sonnel. The service must also include provision of emergency medical or surgical care in women
with severe abortion complications. Developing appropriate services at the primary level of care
with a functioning referral system and the inclusion of post abortion contraceptive care with
counseling are essential facets of abortion care.

Key words: abortion legislation; contraception; manual vacuum aspiration; maternal mortality;
postabortion care; unintended pregnancy; unsafe abortion.

INTRODUCTION

It is estimated that – globally – unsafe abortions are responsible for 67,900 maternal
deaths annually, accounting for 13% of total maternal mortality.1 The marked dispar-
ities between countries in abortion-related mortality are associated with differences
in abortion legislation, dominant religion, socioeconomic status, contraceptive cover-
age, and the availability of accessible effective comprehensive abortion care services.
The most common mode of death is septic shock with multiorgan failure, with or
without haemorrhage. These deaths are preventable and represent a tragic unneces-
sary loss of women’s lives.2

* Mowbray Maternity Hospital, P/Bag Mowbray, Cape Town 7705, South Africa.
E-mail address: sfawcus@pqwc.gov.za
1521-6934/$ - see front matter ª 2007 Elsevier Ltd. All rights reserved.
534 S. R. Fawcus

DEFINITIONS AND TERMINOLOGY

Unsafe abortion: a procedure ‘‘characterized by the lack or inadequacy of skills of the

provider, hazardous techniques and unsanitary facilities’’.3 This definition was formulated
by a World Health Organization (WHO) technical working group in 1992 with the aim of
directing the focus to the safety of the abortion procedure rather than the legality or
whether it was induced. It thus covers pregnancies terminated by unskilled personnel
or self-induced that have adverse sequelae, both in countries with restrictive abortion
legislation and also in those with enabling legislation but limited availability of functioning
facilities to provide the service. It would also include spontaneous miscarriages in which
sepsis or other complications have developed. The term ‘‘unsafe abortion’’ is preferable
to previous terminology: terms such as ‘‘back street abortion’’, ‘‘illegal abortion’’ and
‘‘criminal abortion’’ have all been used; they have judgmental inferences and are difficult
to measure accurately. Also, in some circumstances, abortions performed ‘‘illegally’ in
countries with restrictive legislation can be performed safely with no adverse sequelae.
Miscarriage and termination of pregnancy (TOP): a miscarriage refers to a spontane-
ous pregnancy loss before 22 completed weeks or of a fetus weighing less than 500 g.
This term is preferred (rather than ‘‘abortion’’) for pregnancy loss that is not induced.4
In countries where pregnancies can be and are terminated legally, the term ‘‘termina-
tion of pregnancy’’ is used to refer to induced abortion. In countries with restrictive
abortion legislation, a woman admitted with an incomplete miscarriage is unlikely to
divulge to the health worker as to whether it was really induced, making it difficult
to know if an admission for incomplete abortion is a spontaneous miscarriage or
self-procured termination of pregnancy. This is why it is still necessary to retain the
term ‘‘unsafe abortion’’ for these situations.
Unsafe abortion incidence rate: the number of unsafe abortions per 1000 women in
the reproductive age group (15–49) per year.1
Unsafe abortion incidence ratio: the number of unsafe abortions per 100 live births.1
Unsafe abortion mortality ratio: total number of maternal deaths due to unsafe
abortion per 100,000 live births.1 Abortion-related deaths would be classified as direct
maternal deaths.
Unsafe abortion case fatality rate: the number of deaths due to unsafe abortion
expressed as a percentage of the total number unsafe abortion procedures.1

UNSAFE ABORTION

It is estimated that, of the 210 million women who become pregnant each year, 80 mil-
lion have unintended pregnancies. Of these, 46 million are terminated voluntarily: 27
million legally and 19 million outside the legal system.5

Criteria for describing abortions as ‘unsafe’

The South African National Incomplete Abortion Study, conducted in 1994, developed
an abortion morbidity classification system (Table 1). This is a useful tool for identifying
an abortion as unsafe.6 It was an elaboration of previous attempts by WHO and other
researchers to categorize the morbidity of abortion admissions.7,8
Using this classification, the study, which was conducted in 56 public-sector South
African hospitals in 1996, investigated 803 women admitted with incomplete abortions.
Of these, 15% had severe and 19% moderate morbidity, indicating that 34% of these
 Maternal mortality and unsafe abortion 535

Table 1. Unsafe abortion defined by morbidity severity categories.

Severity categories Definition
Low Temperature  37.2  C and
No clinical signs of infection and
No system or organ failure and
No suspicious findings on evacuation
Moderate Temperature 37.3e37.9  C or
Offensive products or
Localized peritonitis
High Temperature  38  C or
Organ failure or
Peritonitis or
Pulse  120 or
Death or
Foreign body/mechanical injury on evacuation

hospital admissions were for unsafe abortions. This approach was subsequently used in
Kenya, where it was found that 44.2% of emergency abortion admissions were unsafe.9
Spontaneous first-trimester miscarriage is more common than second trimester,
the latter accounting for less than 20% of spontaneous miscarriages. In countries
with high rates of unsafe abortion, second-trimester abortions might account for
nearly 40% of emergency admissions suggesting that they are not spontaneous.6,9

Epidemiology of unsafe abortion

There is paucity of accurate statistics on the incidence of unsafe abortion, particularly in

under-resourced countries with poor health information systems and in countries with
restrictive laws, where such cases might not be reported if procured clandestinely. The
WHO Department of Reproductive Health maintains a database on unsafe abortion and
its associated mortality.1 Data is obtained from records of hospital admissions and com-
munity surveys. Whereas data might be accurate in well-resourced countries, in most
under-resourced countries they are estimates only. WHO data provide the following es-
timates: 97% of unsafe abortions occur in under-resourced countries. The unsafe abor-
tion incidence rate varies from 2 per 1000 women in well-resourced countries to 16 per
1000 in under-resourced countries. In Western Europe, the incidence rate is so low as to
be negligible. In under-resourced countries, the incidence rate varies from 31 per 1000
women in East Africa and 34 per 1000 in South America to a negligible figure in Eastern
Asia, where unsafe abortion is very rare. The same report suggests that there was a de-
cline in the unsafe abortion incidence rate from 1995–2000 in Central America, the
Caribbean and Middle, Eastern and Western Africa.
A study compiling hospital admissions for abortion complications from 13 under-
resourced countries showed annual hospitalization rates as low as 3 per 1000 women
in Bangladesh, about 9 per 1000 in Latin America and 15 per 1000 in Egypt and
Uganda.10 Such figures give some indication of the magnitude of the problem, but
do not reflect it accurately as many women will never access hospital.
In Africa, teenagers account for a large percentage of women with unsafe abortion;
60% of unsafe abortions are in women less than 25 years old, as compared to 30% in
536 S. R. Fawcus

Asia. There is particular concern about the increasing numbers of unsafe abortions in
15- to 19-year-olds in Africa.2

Background determinants of unsafe abortion

These can be divided into the reasons for unintended unwanted pregnancy and the
reasons why the abortion was unsafe.

Reasons for unintended and unwanted pregnancy

These are many: financial hardship, lack of social support, desertion by partner, sexual
abuse, interference with studies/training, and contraceptive failure or non-availability.2 A
qualitative study of Nigerian adolescents indicated that many seeking abortion had not
been motivated to use contraception.11 A case-control study in Zimbabwe identified
lack of social support as an important factor.12 Globally, it is estimated that 120 million cou-
ples have an unmet need for contraception, particularly in under-resourced countries.5
Contraceptive services are not always readily accessible for the young teenager or the
older women (over 40years).13 The decision to terminate can be viewed as a desperate
but often responsible decision not to pursue a pregnancy when the social and economic
circumstances are not favorable. This includes, particularly in Asia and Latin America, mar-
ried women with children who cannot cope financially with another pregnancy. In Africa,
there is a disturbing increase in nulliparous teenagers procuring abortions. Interestingly, in
countries with high rates of unsafe abortion there is a positive correlation with increasing
education, the least educated women in rural areas being less likely to pursue induced abor-
tion.14 High levels of violence against women remain a major problem in many societies.
In some well-resourced countries, such as the UK, there is also concern about the
increasing number of teenage pregnancies and qualitative research directed at ascer-
taining underlying circumstances suggesting that in some cases there might be a sub-
conscious motivation for pregnancy.

Reasons the abortion was unsafe

When unintended pregnancy leads to a decision to terminate, then the reason that the
procured abortion is unsafe would be due to it being illegal and abortion providers
being unskilled; or, in the context of legality, there being inadequate services, leading
to delays and late presentation when the pregnancy has advanced to the second tri-
mester, which is associated with more complications.1
In addition, provider unwillingness due to moral disagreements with TOP and the
international ‘gagging’ rule, whereby some international agencies provide aid for health
programs in under-resourced countries conditional on them not including abortion
care programs, can further impede the development of quality abortion care ser-
vices.2,15 Women’s health services are often not given priority in health service re-
source allocations and so services remain underdeveloped and underskilled.16

Methods of unsafe abortions

Over the years, many have been described:2

 Oral ingestion of herbal medications, quinine, and strong teas have all been
described.11
 Maternal mortality and unsafe abortion 537

 Abdominal massage, which can lead to trauma.

 Local methods, including douches with noxious substances, and enemas.
 Twigs, knitting needles and catheters placed through the cervix, often in unsterile
conditions.

In the Dominican Republic, it has been suggested that the over-the-counter pur-
chase of misoprostol, a synthetic prostaglandin, might have led to this method replac-
ing previous, more dangerous methods, accounting for the falling incidence of unsafe
abortions.17 However, unregulated use of misoprostol also has adverse sequelae; these
will be discussed later.

Morbidity and mortality associated with unsafe abortion

Morbidity and mortality from unsafe abortion depends on the procedure used, the skill
of the provider and whether the procedure is carried out using sterile techniques. In
addition, the general health of the women influences her outcome, as does the gesta-
tional age of the pregnancy; second-trimester procedures being associated with
greater morbidity than those in the first trimester. Another factor determining out-
come is the availability and quality of medical back-up when complications arise.1
The most common morbidities associated with unsafe abortion are sepsis and hae-
morrhage. In addition, trauma from foreign bodies and metabolic complications associ-
ated with renal failure can arise from ingestion of chemicals for abortion. The sepsis
results from a combination of retained products, trauma and non-sterile techniques.
It can be compounded by late presentation at a health facility because of fear of criminal
investigations. Uterine sepsis, if not treated or if treated inadequately, can lead to uterine
necrosis with peritonitis, septic shock and various organ failures (paralytic ileus, dissem-
inated intravascular coagulopathy, adult respiratory distress syndrome, liver dysfunction
and renal failure). Severe haemorrhage can result in death from hypovolemic shock and
coagulopathy. Trauma of the genital tract can cause death by sepsis or haemorrhage. It
can result from bowel trauma from sharp objects passed through the cervix, which per-
forate the uterus and damage the bowel. Common organisms are Gram-negative, anaer-
obic, and also Gram-positive bacteria, which are part of the vaginal flora. Occasionally,
clostridial infections can occur in very unsterile conditions.18 Long-term complications
of survivors of severe morbidity include infertility and chronic pelvic pain.
In countries where there is poor access to safe induced abortion, admissions to
health facilities for septic abortion are very common and account for considerable
part of the health budget.13,19,20. It is estimated that at least 67,900 women die annu-
ally from complications of unsafe abortion, the majority in Africa and Asia.1 The case
fatality rate is estimated to be 367 per 100,000 unsafe abortions (0.37%), and is four
times greater in under-resourced than in well-resourced countries.
In different countries, the proportion of maternal deaths related to unsafe abortion
varies from 1% to 49%.2 The unsafe abortion maternal mortality ratio (MMR) is esti-
mated to be about 50 per 100,000 live births globally. In East Africa it is estimated to
be 140 deaths per 100,000 live births whereas in Latin America it is 30; in Sweden,
rates are so low as to be negligible. The 2000–2002 UK Confidential Enquiry into Ma-
ternal Deaths gives a legal termination of pregnancy maternal mortality rate of 0.15
per 100,000 maternities.21
Most of these data are estimates from facility-based information. A study in Mexico
in which a verbal autopsy technique was used as part of a community-based survey
538 S. R. Fawcus

indicated significant underreporting of second-trimester abortion-related deaths that

were not known to the formal health system.22 The authors suggest that abortion-
related deaths are more likely to be underreported than other causes of maternal
death.
In countries, with a high prevalence of HIV, it might be expected that sepsis asso-
ciated with abortion would be increased in both induced and spontaneous abortions.
As yet there are no good data to verify this.

PREVENTION OF MATERNAL MORTALITY DUE TO UNSAFE

ABORTION

This includes primary prevention (prevention of unintended unwanted pregnancy),

secondary prevention (enabling abortion legislation and the provision of accessible
safe comprehensive abortion care) and tertiary prevention (the provision of skilled
emergency care for severe abortion complications).

Primary prevention

Health education and empowerment of women

It is important that sex education for boys and girls in schools focuses on determinants
of behavior, such as peer pressure, as well as on acquisition of knowledge about sex-
uality, safe sex practices and pregnancy.23 The current AIDS pandemic in many coun-
tries has encouraged this type of education. It is necessary to focus on empowering
teenagers and young women to resist non-consensual sex, although when associated
with violence or economic bribery, this becomes a problem of society not doing
enough to protect vulnerable women.
WHO states that unsafe sex is the second most important risk factor for death and
disability in the world’s poorest population.24 It is unfortunate that sexual and repro-
ductive health targets were not included directly in the Millennium Development
Goals. The International Conference on Population and Development in Cairo in
1994, stressed the importance of sexual and reproductive rights for women and
moved the focus of programs away from population control towards promoting the
human and reproductive rights of women in the context of public health. Reproductive
health incorporates contraception, sexually transmitted infections (STIs) and HIV, cer-
vical screening, and safe abortion. These components should be developed in the con-
text of promoting women’s right to education, employment and empowerment in
relation to male sexuality. Obstetricians and gynecologists have a duty to act as advo-
cates for the women for whom they care.25
In countries where abortion legislation is not restrictive, it is important that the
community and women are educated about their rights within the law, and are in-
formed by the health sector about where termination of pregnancy (TOP) services
can be accessed.

Contraception
Effective contraception can reduce but never eliminate the need for termination of
pregnancy. In countries with good uptake of contraception, there are still unintended
pregnancies requiring TOP.26 This is due to contraceptive failure, particularly with bar-
rier methods and oral contraceptive pills. It indicates the importance of adequate
 Maternal mortality and unsafe abortion 539

counseling when administering a method, especially contraceptive pills stressing the

reasons for failure such as diarrhea, default and antibiotics. Discussion about and pro-
vision of emergency contraception should be seen as a ‘second chance’ at pregnancy
prevention and provided in addition to the regular method. However, a recent survey
among women attending for antenatal care and abortion in Scotland found that, de-
spite campaigns to promote emergency contraception, only 11.8% of those presenting
for abortion had used emergency contraception and there were failures among some
women who used it frequently instead of regular contraception. The authors con-
cluded that, although emergency contraception is an important adjunct, the focus still
should be on provision of effective primary methods of contraception.27
In countries with a poor uptake of contraception due to poor service provision,
non-use of contraception coupled with no knowledge of or poor access to emergency
contraception are important reasons for unintended pregnancy. In the South African
incomplete abortion study, only 53.5% women presenting with an abortion complica-
tion had ever used contraception.6
A similar study in Kenya showed that, of women presenting with an abortion com-
plication, only 14% had used contraception prior to the current conception and only
34% had ever used contraception.9
Although it is common, in most countries, to provide contraception to postpartum
women, important groups of women might be neglected in terms of effective contra-
ceptive provision: young teenagers, women aged over 40 years and women immedi-
ately post-abortion. More ‘youth friendly’ contraceptive services are essential. In
addition, the importance of post-abortal contraception has been emphasized recently
in international programs.28 In Zimbabwe, a post-abortion care study illustrated the
importance of post-abortion provision of contraception in preventing future unwanted
pregnancy.29
Due to the demographic transition, the introduction of contraceptive services in
a country for the first time initially increases the demand for TOP, because it accom-
panies a rising awareness of women about choice over fertility. When services are es-
tablished it will lead to a decline in the need for TOP.13 In some countries, such as the
previous USSR and former Yugoslavia, abortion was legalized without concurrent im-
provement of Family Planning services and was associated with abortion being seen as
a method of family planning.30

Secondary prevention

Enabling abortion legislation

A systematic assessment of the relationship between legal grounds for abortion in na-
tional laws and unsafe abortion is provided by Berer.31 The analysis is based on WHO
2000 estimates of unsafe abortion incidence and associated mortality.1 Data from 165
countries clearly demonstrate that the incidence of unsafe abortion and maternal mor-
tality from unsafe abortion is highest in countries with restrictive abortion legislation;
for example, in countries with restrictive laws, the incidence of unsafe abortion is 23
per 1000 women (15–49 years) compared to 2 per 1000 in countries with liberal laws.
Also, in countries with restrictive laws, the MMR due to unsafe abortion is approxi-
mately 34 per 100,000 live births, compared with 1 or less in those with liberal laws.
Sixty-one per cent of the world’s population lives in countries with laws that permit
TOP for a variety of reasons. Twenty seven per cent, mostly in poor countries, live in
countries with restrictive legislation, often introduced by colonial governments.
540 S. R. Fawcus

The effects of changing the legality of abortion are well illustrated in Romania,
where mortality due to unsafe abortion decreased with liberalization of the abortion
law, but reversed when the law was again made restrictive by the Ceauscescu regime.1
Since 1980, at least 20 countries have increased access to legal abortion.13 There ap-
pears to be advocacy for this development in many other countries, including some in
Sub-Saharan Africa.32 There is evidence to show that, as abortion is made legal, in the
context of adequate contraceptive services, admissions due to unsafe or complicated
abortions are reduced. Although the numbers of induced abortions increase, this is ac-
companied by a decrease in abortion admissions with severe morbidity. This was shown
in the UK after liberalization of its law and more recently in South Africa.21,6
Unfortunately, in some countries, liberalization of abortion laws was not accompa-
nied by a decrease in admissions for unsafe abortion or mortality. Zambia and India are
such examples.33,34 In the former, bureaucratic aspects to the law in terms of consent
and, in both, inadequate provision and poor quality of services within the public sector,
were obstacles to adequate implementation of the law.
South Africa enacted a liberal abortion law in 1996; the Choice on Termination of
Pregnancy (CTOP) Act. Before the date of implementation, a task team was consti-
tuted with the aim of planning implementation, devising a management protocol
that could be easily implemented at primary levels using doctors and trained midwives,
identifying sites, and arranging training programs for providers.35 This prevented some
of the problems that arose in Zambia after liberalization and enabled the development
of TOP services in many sites. However, there is an ongoing challenge to make TOP
services accessible to all women and still a sizeable fraction present with unsafe abor-
tions procured outside of designated facilities.36 An important problem identified in
South Africa was that of provider unwillingness, sometimes related to conscientious
objection. Values clarification workshops were initiated to help engender the respect
of health workers towards each other and their patients despite differing views on the
morals of TOP. The CTOP Act clearly stipulates that all women have a right to infor-
mation about TOP services and that no-one should obstruct this right. The profes-
sional associations for doctors and nurses in South Africa have stipulated that all
health workers are obliged to treat a woman with an emergency admission for com-
plicated septic abortion, however it was procured.35

Provision of comprehensive safe abortion care services

This section covers both safe services for induced abortion (TOP) within a legal frame-
work, and good quality services for women admitted with incomplete abortions. In
countries with liberal laws and easy access to induced abortion, then most emergency
admissions for incomplete abortion are likely to be spontaneous miscarriages. How-
ever, in countries with restrictive or poorly implemented laws, many hospital admis-
sions of women are incomplete abortions that could have been induced, but this
cause is not divulged to the health worker. It is suspected when there is associated
morbidity.
To provide a safe abortion service at all levels of care, using providers who are not
necessarily gynecologists – such as junior doctors, general medical practitioners, and
nurses – there has been an impetus to identify management methods with the least
complications, for which training can be feasibly provided.37

First-trimester termination of pregnancy. In first-trimester induced abortion, the use of

prostaglandins to prime the cervix prior to surgical evacuation prevents difficult
 Maternal mortality and unsafe abortion 541

cervical dilatation and has been demonstrated in several studies to be effective.38 In

addition, suction evacuation of uterine contents has replaced sharp curettage as the
method of choice due to perceived advantages in speed, comfort and safety. A recent
Cochrane review identified only three trials of adequate quality to compare vacuum
aspiration with sharp curettage for surgical termination of first-trimester pregnancy.39
The review confirmed that vacuum aspiration has a significantly shorter procedure
time, but found a similar efficacy and side-effect profile. Misoprostol as a cheap
form of prostaglandin, and the hand-held manual vacuum aspiration syringe, are
both affordable technologies in poor countries, and can be performed at all levels
of care. They are possibly a contributing factor to the successful implementation of
South Africa’s CTOP Act, where they form part of the national protocol.35
In early first-trimester TOPs (gestation less than 7 weeks), medical management
alone is adequate, using a combination of mifepristone and misoprostol.40 Back-up fa-
cilities for ultrasound to confirm that the uterus is empty, and access to follow-up, is
important. Medical methods are popular and acceptable to women in well-resourced
countries. In under-resourced countries, their use might be limited by non-availability
of mifepristone and ultrasound facilities, and the fact that few women present for TOP
before 8 weeks, which is the preferred time for medical termination.
In some countries with restrictive abortion legislation, there is evidence of self-use
of misoprostol, and women then present to facilities with an incomplete abortion. Ex-
tensive use of misoprostol has been reported in Brazil, Guatemala and the Dominican
Republic. In the last, it is thought to be the reason why hospital admissions for abor-
tion are associated with less morbidity.17 Although procured outside the law, miso-
prostol is a less dangerous form of self-induced abortion than previously used
methods, such as sharp objects or chemical douches. However, it is still necessary
to regulate the use of misoprostol and it should not be an over-the-counter medica-
tion. If given clandestinely to procure abortion for a woman who has a pregnancy more
advanced in gestation than is realized, it might result in rupture of the uterus, or even
in preterm delivery. Also, a specific congenital deformity – the Mobius sequence – has
been identified in women who failed in their attempt at self-induced abortion with
misoprostol and proceed to term delivery.41

First-trimester incomplete abortion. For women presenting with first-trimester incom-

plete abortions, the standard treatment for many years has been to evacuate the
uterus. Vacuum aspiration using the manual vacuum aspiration (MVA) syringe is the
method of choice recommended by WHO.37 The 2000 Cochrane review identified
two eligible trials comparing vacuum aspiration with sharp curettage and showed
that the former was associated with statistically less blood loss, less pain and shorter
procedure time.42 One of the trials suggested that the risk of perforation was greater
in the sharp curettage group but the numbers were too small to be reliable for this
outcome.
Early Pregnancy Assessment Units in many well-resourced countries now allow
women a choice of immediate suction evacuation, medical management (use of miso-
prostol to complete uterine emptying) or expectant management (allowing the abor-
tion to complete itself naturally), provided there is not excessive bleeding or evidence
of infection.43 The last two options require good patient counseling and might also re-
quire ultrasound follow-up. Ten to twenty per cent of these patients will require uter-
ine evacuation at a later stage. However, the immediate evacuation group has slightly
more infection. There are no studies evaluating expectant or medical management in
under-resourced countries, where the preferred treatment offered is still uterine
542 S. R. Fawcus

evacuation. Given more difficulties in following up patients, lack of ultrasound at pri-

mary level, the possibility of untreated STIs, and high HIV prevalence, it could be ar-
gued that expectant or medical management might not be appropriate. Further
research would be valuable in this context.

Prophylactic antibiotics. The use of prophylactic antibiotics has been evaluated for first-
trimester abortion and miscarriage. There is evidence that it reduces subsequent in-
fection for TOPs.44 There is insufficient evidence to indicate whether they should
be used for incomplete miscarriages.45 In the UK, screening for Chlamydia trachomatis
is suggested for all women with first-trimester TOPs and miscarriage.40 In under-
resourced countries, some incomplete miscarriages might have been induced and
screening for sexually transmitted infections is rarely done, so there are more indica-
tions for prophylactic antibiotics.

Analgesia/anesthesia. First-trimester suction evacuation of the uterus requires some

form of analgesia and/or anesthesia. If the cervix is closed, a paracervical block pro-
vides effective analgesia for cervical dilatation. If the cervix is open, this might not
be necessary and some form of conscious sedation is usually adequate for the suction
evacuation. There are reports of uterine evacuation with no extra analgesia provided
the cervix is open, and there is a support person for the women. The shift to con-
scious sedation with or without paracervical block allows these evacuation procedures
to be done outside a formal operating theatre, which means they can be done with less
delay. This reduces the risk of complications and allows a shorter hospital stay.37 There
is a need for more research on women’s perception of pain and discomfort during
these procedures to evaluate optimal analgesic requirements.
General anesthesia is rarely required for such procedures, but might be considered
in specific instances, such as a young rape survivor.
Second-trimester procedures. Second-trimester procedures are associated with greater
morbidity than those occurring in the first trimester. In well-resourced countries,
medical termination involves mifepristone followed by prostaglandins, gemeprost or
misoprostol, given vaginally.18 Suction evacuation might be required if the placenta
appears incomplete.
Dilatation and evacuation (D&E) is an alternative, which requires greater skill, ultra-
sound guidance and general anesthesia. Comparative trials have confirmed its safety in
skilled hands. There is a need for randomized controlled trials comparing surgical and
medical methods of second-trimester TOP.18
Extra-amniotic and intra-amniotic infusions of prostaglandin agents such as F2 alpha
and E1 are now second-line procedures if the mifepristone/misoprostol regime fails.
Mifepristone is not available in most under-resourced countries. Also, the skill of
D&E, with the accompanying need for ultrasound and general anesthesia, means it is
less frequently used as a method. In these situations, misoprostol can be used alone
for second-trimester termination. The dose to delivery interval is longer than when
given after mifepristone.
Hysterotomy is occasionally required for failed procedures, and possibly in selected
women with scarred uteri.
In women admitted with an incomplete second-trimester abortion, misoprostol or
intravenous oxytocin can be used to promote expulsion of the fetus, followed by uter-
ine evacuation, if necessary. Prophylactic antibiotics are usually recommended for
second-trimester procedures but this has not been subjected to trials.
 Maternal mortality and unsafe abortion 543

Tissue inspection. It is not necessary routinely to send aspirated products of concep-

tion for histological examination. However, visual inspection is recommended to con-
firm pregnancy products, exclude ectopic pregnancy and identify abnormal gestational
trophoblastic tissue.18,37

Post-abortion care. Post-abortion care has been identified as a very important component of
secondary prevention.28,29,46 It should involve provision of contraception, counseling about
STI prevention and use of barrier methods, prophylactic antibiotics, and counseling about ad-
verse complications from the procedure. The woman should be provided with information
as to where she should go if she has any complications and requires emergency care. Clear
referral routes for management of further complications after discharge are essential.
Training health workers as providers of abortion care must include the above as-
pects of post-abortion care if it is to have an effective public health impact. Table 2
summarizes the essential components of comprehensive safe abortion care.
Policies and guidelines for safe abortion care need to be accompanied by effective
implementation. Healy et al describe a useful monitoring tool that can be used to per-
form a type of criterion-based audit to monitor countries, facilities or regions with
respect to provision of safe abortion care.47

Tertiary prevention

Correct and timely referral and management of women with unsafe abortion can re-
duce maternal deaths. The classification of unsafe abortion used in this section will be
that described in the South African 1994 study.6

Table 2. Essential components of safe abortion care.

Accessible services: services at level 1 (clinic and district hospital) with referral route to level 2 or 3
hospitals for complications
Provider willingness
Equipment, medications and skills available for:
Safe TOP (law permitting)
T1 TOP Mifepristone þ misoprostol
Misoprostol þ MVA*
T2 TOP Mifepristone þ misoprostol
Misoprostol*
D&E
Equipment, medications and skills available for:
Management of incomplete abortion
T1 ICA Expectant
Misoprostol
MVA*
T2 ICA Misoprostol*
or
oxytocin*
Post-abortion care e counseling about sexually transmitted infections
e provision of contraception
e instructions about potential complications and where they can be managed
D&E, dilatation and evacuation; ICA, incomplete abortion; MVA, manual vacuum aspiration; T1, first
trimester; T2, second trimester; TOP, termination of pregnancy.
*
More appropriate in under-resourced settings.
544 S. R. Fawcus

Haemorrhage
An unsafe abortion in which there is severe haemorrhage requires resuscitation with
crystalloids and blood, together with urgent uterine evacuation. Fresh frozen plasma
may be necessary if coagulopathy develops.

Moderate sepsis/morbidity
An unsafe abortion with moderate morbidity from sepsis – pyrexia, tachycardia, uter-
ine tenderness, and retained products of conception – requires further evaluation for
evidence of organ failure: full blood count, blood culture and renal function tests.
Treatment involves intravenous fluids, intravenous broad-spectrum antibiotics and
evacuation of the uterus. This is best done using suction curettage under general an-
esthesia. Such patients need to be admitted as inpatients and observed for a minimum
of 48 hours after the procedure or until the temperature and signs settle. This prob-
lem could be managed at a level one or district hospital.37,48

Severe sepsis/morbidity
Women with severe morbidity, in addition to the above signs, might also have gener-
alized peritonitis, organ failure and/or septic shock. Management involves assessment
for organ failure: full blood count, blood culture, renal function tests, liver function
tests, coagulopathy screen and chest X-ray. Treatment involves resuscitation with in-
travenous fluids, urinary catheterization and monitoring of urine output, consideration
of central venous pressure monitoring, and monitoring in a high care or intensive care
area. In severe cases, ventilation and ionotropic support might be necessary. Definitive
treatment would include intravenous broad-spectrum antibiotics and evacuation of the
uterus. Laparotomy with drainage of pus, or – more frequently – hysterectomy, is nec-
essary if there is no response to the above treatment, there are signs of deteriorating
organ failure or multiorgan failure, and/or septic shock requiring ionotropes. Coagul-
opathy would need to be corrected, with fresh frozen plasma or other blood products;
a nasogastric tube might be necessary for paralytic ileus. Level one/district hospitals need
to refer such patients urgently after initial resuscitation, uterine evacuation and com-
mencement of intravenous antibiotics. Maternal deaths from severe abortal sepsis will
occur if there are delays in performing necessary surgery and/or there is inadequate
treatment of organ failure.48 Avoidable factors identified in a Zimbabwean study and
in the South African Confidential Enquiry included: delay in referral from district or level
one hospital to secondary or tertiary care, and prolonged attempts at antibiotic treat-
ment in situations where surgery was indicated following poor response to 48 hours
of antibiotics. There were also delays in performing life-saving hysterectomies.12,48
The algorithm in Figure 1 is derived from South African National Committee on
Confidential Enquires into Maternal Deaths booklet on emergency management of
common obstetric and neonatal emergencies. It summarizes the approach to manage-
ment of women with severe morbidity from unsafe abortion.49 The antibiotic regimens
marked with an asterisk (*) are those recommended in South Africa but can be
modified according to local protocols and availability.
The costs to the health sectors of treating women with severe morbidity would be
easily outweighed by the costs of providing larger numbers of women with safe legal
terminations of pregnancy. In addition, the emotional and physical cost of unsafe abor-
tion to the women herself, and to her family, is entirely preventable by the provision of
comprehensive safe abortion care.
 Maternal mortality and unsafe abortion 545

SUMMARY

Unsafe abortion remains an enormous preventable tragedy in many under-resourced

countries, although there are indications that the incidence and associated mortality is
decreasing in some countries. The WHO assembly in 1967, the program of action of
the International Conference on Population and Development (1994) and the World
conference on Women in Beijing in 1995, all reiterated the extent of the serious health

Yes
Patient presenting with Resuscitate the
Shocked?
an abortion/miscarriage patient

No

Assess the patient according to

organ systems

Safe abortion Severe unsafe abortion

Unsafe abortion

Assess for organ system

Manual dysfunction with special
vacuum Assess for organ system
aspiration dysfunction with special investigations
Metronidazole* investigations
2 g p.o. stat
Doxycycline*
200 mg p.o.
stat

If more than two

systems affected:
No organ systems affected
Therapeutic antibiotics:
Zinacef 750 mg t.d.s. ivi*
Metronidazole 1 g b.d. pr*
Gentamicin 240 mg imi* Therapeutic antibiotics:
daily if no renal impairment Zinacef 750 mg t.d.s. ivi*
Evacuation in theatre Metronidazole 1 g b.d. pr*
Monitor clinical response Gentamicin 240 mg imi* daily if no
Repeat special investigation within renal impairment
12 h of evacuations

If response discharge on oral If no response or if

Hysterectomy
antibiotics after 48 h deterioration

Figure 1. Algorithm for management complicated abortion/miscarriage.

546 S. R. Fawcus

consequences of unsafe abortion for women and the need for individual countries to
take action.2
The reduction of maternal mortality and morbidity from unsafe abortion requires:

 Effective accessible services for contraception, comprehensive abortion care and

management of severe abortion complications.
 Training of all levels of health worker in comprehensive abortion care.
 Reform of abortion legislation in countries with restrictive laws.
 Counselling and education around unsafe sex, unintended pregnancy and sexually
transmitted infections, in particular HIV/AIDS.

Practice points

 Irrespective of the status of laws governing TOP, health practitioners are eth-
ically obliged to treat all women admitted with unsafe abortion in an effective,
appropriate and non-judgmental manner.
 Improving contraceptive coverage to teenagers, older women, post-abortal
women, in addition to postpartum women, is essential to reduce the incidence
of unintended pregnancies.
 The manual vacuum aspiration syringe is an effective instrument for evacuating
the uterus in incomplete abortion, and after cervical priming in first-trimester
TOPs.
 Misoprostol is an important medication for priming the cervix in first-trimester
TOPs and for initiating/completing TOP/ICA in the second trimester.
 Where available, mifepristone followed by misoprostol, can enable medical
abortion alone.
 The management of an abortion complicated by severe haemorrhage and/or
sepsis constitutes a serious emergency, requiring aggressive treatment focusing
on uterine evacuation, treating organ failure and hysterectomy if these mea-
sures fail.
 Post-abortion care is an essential component of management of women with
unsafe abortion.

Research agenda

 Evaluation of interventions to reduce unintended teen pregnancy.

 Evaluation of perceived contraceptive needs of women over 40 years.
 Medical TOP and medical management of incomplete abortion in under re-
sourced countries – feasibility and safety.
 Value of prophylactic antibiotics in incomplete abortion.
 Second trimester procedures; medical versus surgical in developing countries.
 Near miss audits for unsafe abortion.
 Maternal mortality and unsafe abortion 547
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