Morbidity and Mortality following Induced Abortion in Nnewi, Nigeria

Abstract

We present a study of the maternal morbidity and mortality among 76 patients treated at the Nnamdi Azikiwe University Teaching Hospital, Nnewi for complications of induced abortion from January 1996 to December 2000. The total number of maternal admissions over this period was 5750, and illegal induced abortion was responsible for 1.3% of the admissions, with a mortality rate of 5.3% ( n=4) for induced abortion. This accounted for 21.1% of the total maternal deaths ( n=19) for the period. The mean age of the women was 20.6 years (range 15–34 years), 94.7% ( n=72) were unmarried, 93.5% ( n=71) were nulliparous and 76.5% ( n=58) were unemployed, 67.1% ( n=51) had had a mid-trimester termination at > 13 weeks gestational age. It is significant that 55.3% of the patients were teenagers and 45.1% of the mid-trimester abortions occurred in this group. Genital sepsis, haemorrhage, pelvic infection with peritonitis and abscess formation, uterine perforation, and gut injury were the major complications encountered.
This study demonstrates that induced abortion is still a major cause of maternal mortality in Nigeria. Integrated family health education, planned parenthood and contraceptive education, a mass literacy campaign and improvement of the existing national health services are recommended in order to ameliorate the problems of illegally induced abortion in Nigeria.

Full text

Tropical Doctor. 2003: 33: 170 – 172. Ikechebelu JI & Okoli CC.
Morbidity and mortality following induced abortion in Nnewi, Nigeria.
J I Ikechebelu FWACS FICS C C Okoli MBBS
Department of Obstetrics & Gynaecology, Nnamdi Azikiwe University Teaching Hospital, PMB 5025,
Nnewi, Nigeria.
Correspondence to: Dr J I Ikechebelu, Department of Obstetrics & Gynaecology, College of Medicine,
Nnamdi Azikiwe University, PMB 5001, Nnewi Campus, Nigeria
E – mail: jikechebelu@yahoo.com
TROPICAL DOCTOR, 2003,33, 170-172
SUMMARY we present a study of the maternal morbidity and mortality among 76 patients treated at
the Nnamdi Azikiwe University Teaching Hospital, Nnewi for complications of induced abortion from
January 1996 to December 2000. The total number of maternal admissions over this period was 5750,
and illegal induced abortion was responsible for 1.3% of the admissions, with a mortality rate of 5.3%
(n=4) for induced abortion. This accounted for 21.1% of the total maternal deaths (n=19) for the
period. The mean age of the women was 20.6 years (range 15-34 years), 94.7% (n=72) were
unmarried, 93.5% (n=71) were nulliparous and 76.5% (n=51) had a mid-trimester termination at >13
weeks gestational age. It is significant that 55.3% of the patients were teenagers and 45.1% of the mid-
trimester abortions occurred in this group. Genital sepsis, heamorrhage, pelvic infection with
peritonitis and abscess formation, uterine perforation, and gut injury were the major complications
encountered.
This study demonstrates that induced abortion is still a major cause of maternal mortality in Nigeria.
Integrated family health education, Planned Parenthood and contraceptive education, a mass literacy
campaign and improvement of the existing national health services are recommended in order to
ameliorate the problems of illegally induced abortion in Nigeria.
Introduction
Induced abortion as a means of terminating pregnancy for medical, social and eugenic reasons is
practiced in many societies. The role played by unsafe induced abortion as an important cause of
morbidity and mortality in Africa has been emphasized by many authors (Oronsaye 1997,
unpublished). The world Health Organization (WHO)
2
in 1990, estimated that about 40-60 million
abortions occur around the World annually and half of these are unsafe, being performed outside
authorized unskilled practitioners or abortionists. Induced abortion in developing countries is believed
to be responsible for about 50-100 women per 100 000 terminations
3
. The international planned
parenthood federation
4
state that 99% of 500 000 maternal deaths from unsafe abortion occur in
Nigeria where induced abortion is variously reported to account for 5-40% of abortions is variously
reported to account for 5-40% of maternal deaths – and a large proportion of these abortions occur in
young women mortality rate, illegally induced abortion in developing countries has been shown to be
associated with serious morbidity and a sevenfold increase in the risk of having secondary infertility
due to uterine synechiae, tubal occlusion, and ectopic pregnancy.

Tropical Doctor. 2003: 33: 170 – 172. Ikechebelu JI & Okoli CC.
The law concerning abortion in Nigeria is embodies in the Offence Against the Persons Act of 1861,
sections 58 and 59 (Box 1). The implication of these sections is that abortion in all its ramifications
attracts a criminal charge punishable, if proven, by life imprisonment
8
.
In this study, the 76 case of illegally induced abortion managed in our centre in Nnewi, Nigeria from
the focus of this discussion. Our main objective is to highlight the morbidity and mortality and to
discuss the possible solutions to the problem of illegally induced abortion in Nigeria.
Materials and methods
The records of 76 patients who were admitted and treated for complications of illegally induced
abortion at the gynaecological unit of the Nnamdi Azikiwe University Teaching Hospital Nnewi,
Nigeria between January 1996 to December 2000 were retrieved from the medical records department
and reviewed.
Important information obtained from each patient’s record included age, parity, employment and
martial status, gestational age, type of practitioner involved and method of termination. Also analyzed
were the complications and the modalities of treatment and the status of the practitioners or
abortionists.
Results
Out of the 76 cases of induced abortion, treated over the 5-year period, January 1996 to December
2000, there were four deaths giving a mortality rate of 5.3% in this group. During the same period
there were 19 maternal deaths in the hospital. Induced abortion accounted for 21.1% of all the maternal
deaths and 1.3% of the total maternal admissions. The difference is significant (P<0.001).
Box 1 section 58 and 59 from the Nigeria Offence Against the persons Act, 1861
Section 58
Every women being with child, who with intent to procure her
own miscarriage, shall unlawfully administer to herself any
poison or other noxious thing or shall unlawfully use any
instrument use any instrument or other means whatsoever with
the like intent shall be liable to be kept in penal servitude for
life.
Section 59
Whoever shall unlawfully supply or procure any poison or other
noxious thing, or any instrument or thing whatever knowing
that the same is intended to be unlawfully used or employed
with intent to procure the miscarriage of the guilty of
misdemeanour, and being convicted thereof shall be liable to be
kept in penal servitude for life.

Tropical Doctor. 2003: 33: 170 – 172. Ikechebelu JI & Okoli CC.
Table 1 shows the age distribution of the patients and the gestational age at the time of the time of the
abortion. Of the patients, 55.3% (n=42) were teenagers and 67% (n=51) had had a second trimester
(late) abortion and the mean age of the women was 20.6 years (range 15-34 years).
Most were secondary school student school students and young school leavers, 94% (n=72) were
single, 3.9% (n=3) were married, one was widowed, one was divorced, and 76% (n=58) were
unemployed.
The various complications encountered varied from genital sepsis (96%) to incomplete abortion
(60.5%), pelvic abscess 21.0%, uterine perforation (3.9%), bowel injury (2.6%). Sepsis was the most
frequent complication found in all except three patients with incomplete abortion. Four died. Many of
the patients had more than one complication (e.g. the 16 with pelvic abscess and peritonitis were
included in the had liferine perforation).
Definitive treatment is shown in Table 2. In addition, all the patient received appropriate antibiotic
therapy; 91.0% (n=69) received a blood.
Discussion
Induced abortion with its attendant sequelae is reported to be increasing in many developing
countries
9
. However in Nigeria only a small proportion of cases of illegally
Table 1 Age distribution and gestational age at termination
Total no. of First trimester Second trimester
Patients abortion abortion
Age (year) No. (%) No. (%) No. (%)
15-19 42 (55.3) 19 (25.0) 23 (30.26)
20-24 19 (25.0) 4 (5.26) 15 (19.74)
25-29 9 (11.84) 2 (2.63) 7 (9.21)
30-34 6 (7.9) 0 (0.00) 6 (7.90)
Total 76 (100.0) 25 (32.90) 51 (67.10)
Table 2 Definitive treatment given for complications from induced abortion
Treatment No. of Patients(%)
Evacuation 46 (60.5)
Laparotomy and pelvic abscess drainage 16 (21.0)
Colostomy 1 (1.3)
Intestinal resection and anastomosis 1 (1.3)
Hysterectomy 1 (3.9)
Laparotomy and repair of uterus 3 (3.9)
Repair of cervical laceration 2 (2.6)

Tropical Doctor. 2003: 33: 170 – 172. Ikechebelu JI & Okoli CC.
Induced abortion reach the teaching hospital due to restrictive abortion laws10, and Anate et al. believe
that for every case that is reported, about 10 will go unreported3. The number of cases of induced
abortion in this study is patients prefer the private specialist hospitals which offer a greater degree of
confidentiality, and only the extremely bad cases of confidently, and only the extremely bad cases
rejected by or referred by these hospitals arrive at public hospitals. It is significant that 55.3% of these
induced abortions occurred in young girls below 20 years of age. Other workers have reported similar
figures1,9 (Oronsaye 1997, unpublished).
Young women constitute the largest group of patients seeking induced abortion and they have a
tendency to present late. This is because abortion is illegal, the women are often young and poorly
educated, they hide both their pregnancy and subsequently the complications of seriously ill11. This
explains the high incidence of serious complications such as sepsis (96.0%), haemorrhage (60.5%) and
pelvic infection with peritonitis and abscess formation (21.0%) necessitating the various modalities of
definitive treatment given in this study. Non-medically qualified practitioners working in an
unhygienic environment carried out most of the attempted induced abortions.
The finding that the young, unemployed, and unmarried recent school leavers and students were at
most risk provides a direction for new strategies for the prevention of the complication of illegal
abortion. This group of women as well as others in senior secondary school classes contraceptive
advice with particular emphasis on the consequences of illegal termination pregnancy.
The continued high level of maternal mortality associated with abortion can be attributed to the non-
enforcement of the abortion law in the country and inadequate health services for victims of attempted
induced abortion1. The present state of non-enforcement of the abortion law in Nigeria tends to
enforcement of the abortion law in Nigeria tends to encourage women faced with the dilemma of
unwanted pregnancy to patronized back with the dilemma of unwanted pregnancy to patronized back-
door abortionists who may not be medically trained, thus leading to increase complications. Rigid
enforcement of the Nigeria abortion law might reverse this trend, although most developed and
developing countries have experienced marked reduction in abortion-related maternal mortality and
morbidity following the liberalization of their abortion laws11-13. However, the law in Nigeria is not
the primary problem – the main contributory factor to the maternal mortality and morbidity rates is the
high rate of unwanted pregnancy due to low use of contraceptives14.
Therefore if the abortion law in Nigeria remains, more effort should be directed at reducing the
incidence of, or completely eliminating, unwanted pregnancy. This will entail the provision of
comprehensive services and a mass literacy campaign. The improvement of the existing national health
services and the introduction of comprehensive post-abortion medical care will reduced the current
high level of mortality and morbidity attributable to induced abortion.
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3. Ikpeze OC. Pattern of morbidity and mortality following Gynaecol 2000; 20:55-7
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