Unsafe - Abortion

Unsafe Abortion:

It is estimated that 40-60 million abortions take place throughout the world and half of them perform unauthorized person mostly in developing countries with grave consequences (WHO, 1990). Health education and community awareness are the basic aspects of its prevention.

Illegal abortions are performed much more frequently in India with their disastrous results even today Inspite of liberalization of the Medical Termination of Pregnancy Act. Two cases of unsafe abortions are reported where the procedure was carried out by doctors without any training in midwifery and family planning. One patient had extensive small bowel injury secondary to uterine perforation but survived whereas the other expired due to septicaemia, peritonitis, disseminated intravascular coagulopathy following uterine perforation.

Induced abortion signifies voluntary or willful termination of pregnancy, whether permitted by law or not, before viability. Induced abortion may be illegal (mostly septic abortions) or legalized abortions usually Medical Termination of Pregnancy (MTP). Unfortunately the decline in illegal abortions that one might have expected when abortions were legalized has not taken place.

The term "unsafe abortion" proposed by the World Health Organization (WHO) lately has been accepted by most other international health institutions. Unsafe abortion means "abortion not provided through approved facilities and/or persons. Unsafe abortion is one of the great neglected problems of health care in developing countries.

Unsafe abortions are performed 15-20 times more often than safe legal abortions in India, at present. Unsafe abortion are mostly performed by untrained village abortionists, chiefly female dais or untrained midwives, village unlicensed doctors called quacks, licensed doctors without any training in midwifery and family planning, as well as trained doctors including gynecologists who do not wish to disclose these procedures for socio-economic and legal reasons. In both these cases, the abortions were performed by doctors without any training in midwifery, and family planning.

It is estimated by the WHO (1994) that in the Indian subcontinent 15-24 unsafe abortions take place per 1000 women aged 15-49 years.It is estimated (WHO, 1994) that in India 70-89 women per 100,000 live births die from unsafe abortion, the risk of death is 1 in 250 procedures. A study on illegal abortion in rural areas, conducted by the Indian Council of Medical Research (ICMR) revealed that the extent of illegal abortion (13.5 per 1,000 pregnancies) in comparison with legal abortion (6.1 per 1,000 pregnancies) was still quite high and the trend in the past 17 years (1972-1989) could not show a tendency for illegal abortion to decline (ICMR, 1989).

In a series of 950 septic abortions, 6.47 per cent i.e. 64 per 1000 cases died. The common causes of death are peritonitis, septicemia, endotoxic shock, hemorrhage and tetanus. The first patient in the study had a very rare type of bowel injury, in addition to ileal perforation. The bowel was pulled through the uterine perforation while its serosa was held back from the level of ileal perforation upto just one foot away from duodena - jejuna junction and was found like the folds of an accordion. The second patient died of septicaemia with endotoxic shock, peritonitis, acute renal failure and DIC. This infection was probably due to lack of adequate aseptic and antiseptic precautions.

Mortality and morbidity rates following illegal abortion are very high and make the life of many women miserable. All attempts must be made to reduce the incidence of illegal abortion by proper legislation, propaganda and increasing availability of contraceptive and abortion services.

Medical Termination of Pregnancy (MTP) is a maternal health care measure, which helps to avoid the maternal mortality and morbidity resulting from illegal abortions. Under the provision of the Act, pregnancies up to 20 weeks can be terminated under the certified opinion of one or two registered medical practitioners depending upon the period of gestation. Pregnancy termination can be performed on humanitarian, eugenic, medical and social grounds. A variety of induced abortion services are available in Asian countries and these may be obtained from

• Government hospitals and centers,
• 2. Municipal hospitals and maternity homes,
• 3. Non-Government organizations (NGO) or voluntary agency clinics, and
• 4. Private hospitals, nursing homes or clinics. The services are completely free of charge/cost in government and municipal centers. It is important to understand that establishment of good abortion services on a completely free basis is a cost benefit measure.

The assertion that abortion is too simple a procedure to warrant formal training is not supported by facts. Complication rates are significantly higher when general physicians, without any training, perform abortions. Examination of rates of complications occurring in a teaching hospital based abortion clinic show that rates are significantly lower for resident physicians after training than before training. The findings demonstrate that first and second trimester abortion techniques can be improved by training and that, when properly supervised trainees can accomplish these procedures safely.

Many of the General practitioners or Primary Health Center (PHC) doctors are unable to provide services when first approached either because of lack of skill to perform the procedure or lack of required physical facilities. A crash training programme, specially for medical officers working at Block level Primary Health Center, in MTP and other surgical procedures is being implemented in four states with the grants-in-aid from the Government of India (Ministry of Health and Family Welfare, Government of India, 1990).

Only after the successful performance of 25 suction evacuations under supervision is the practitioner licensed to perform abortions on his own (Ministry of Health and Family Planning, Government of India, 1975) . The risk of women dying from legal abortion is exceedingly rare. Mortality from legal induced abortions has declined substantially in recent years. It averages 0.6 per 100,000 procedures in the developed countries. The risk is clearly related to the type of procedure used, length of gestation and recognised/unrecognised general health problems present at the time of abortion.