Complications of Unsafe Abortion: A Case Study and the Need for Abortion Law Reform in Nigeria

Abstract

Abstract

Complications of unsafe abortion account for 30–40% of maternal deaths in Nigeria. This paper reports a case of unsafe abortion by dilatation and curettage, carried out by a medical practitioner in a private clinic on a 20-year-old single girl in Lagos, Nigeria. The girl was 16 weeks pregnant. She suffered complications consisting of perforation of the vaginal wall through the utero-vesical space into the abdominal cavity with gangrenous loops of small intestine herniating through it. Information was obtained from her case notes and the operating theatre register. She had a resection and anastomosis of the small intestine and had to remain in hospital, where she made a full recovery, for two weeks. Unsafe abortion is fraught with many complications, including pelvic sepsis, septicaemia, haemorrhage, renal failure, uterine perforation and other genital tract injuries, and gastro-intestinal tract injuries. Where expert, emergency treatment for these is not available, women die. Unsafe abortion procedures, untrained abortion service providers, restrictive laws and high morbidity and mortality from abortion tend to occur together. We advocate for a review of the existing restrictive laws in Nigeria in order to reduce the high morbidity and mortality from unsafe abortion.

Résumé

Les complications consécutives à un avortement à risque représentent 30–40% des décès maternels au Nigéria. Cet article décrit un avortement par dilatation et curetage mené par un praticien médical dans une clinique privée sur une célibataire de 20 ans à Lagos, Nigéria. La patiente était enceinte de 16 semaines. Elle souffrait d'une perforation de la paroi vaginale par l'espace utéro-vésical dans la cavité abdominale, des anses gangrenées de l'intestin grêle formant des hernies. Les informations ont été obtenues à partir de son dossier et du registre de la salle d'opération. Elle a subi une résection et une anastomose de l'intestin grêle et a dû être hospitalisée pendant deux semaines avant de se rétablir complètement. L'avortement non médicalisé comporte beaucoup de complications: infection pelvienne, septicémie, hémorragie, insuffisance rénale, perforation utérine et autres lésions de l'appareil génital, et lésions de l'appareil gastro-intestinal. Quand un traitement spécialisé d'urgence n'est pas disponible, les femmes meurent. Les procédures à risque, les praticiens non formés et les lois restrictives tendent à coı̈ncider avec des taux élevés de morbidité et de moralitédues à l'avortement. Nous plaidons pour une révision des lois restrictives en vigueur au Nigéria afin de ré duire les taux élevé de morbidité et de mortalité dues aux avortements à risque.

Resumen

Entre el 30 y el 40 por ciento de las muertes maternas en Nigeria se deben a complicaciones de abortos practicados en condiciones de riesgo. Este artı́culo describe el caso de una joven soltera de 20 años con 16 semanas de embarazo a quién un médico en una clı́nica privada en Lagos, Nigeria le hizo un aborto por dilatación y curetaje. Ella sufrió como complicaciones la perforación de la pared vaginal atravesando el espacio útero-vesical hasta la cavidad abdominal con lazos del intestino delgado gangrenosos enclavados en ella. Se obtuvo la información de su ficha médica y del registro del quirófano. Le hicieron una resección y anastomosis del intestino delgado, y ella tuvo que permanecer hospitalizada por dos semanas, recuperándose completamente. El aborto practicado en condiciones de riesgo conlleva muchas complicaciones, incluı́das la sepsis pélvica, septicemia, hemorragia, paro renal, perforación del útero y otros daños al aparato genital, y daños al aparato gastrointestinal. Donde no existan tratamientos de urgencia especializados para estas condiciones, las mujeres mueren. Suelen conjugarse las intervenciones malhechas, los proveedores no calificados, las leyes restrictivas y la alta morbi-mortalidad a causa del aborto. Estamos a favor de una revisión de las leyes restrictivas en Nigeria para reducir la alta morbi-mortalidad del aborto inseguro.

Key Words:

• clandestine and unsafe abortion
• maternal mortality and morbidity
• abortion service providers
• Nigeria

As many as 53 million pregnancies are estimated to be terminated by induced abortion each year worldwide [1], while in Nigeria an estimated 610,000 abortions are performed yearly [2]. A significant number of these abortions are thought to be performed by physicians in Nigeria and are generally assumed to be relatively safe [2][3]. However, unsafe abortions remain a major reproductive health concern in Nigeria and indeed in most other parts of the developing world [2]. They are also a major contributor to maternal mortality, accounting for as many as 30–40% of maternal deaths in Nigeria and one in eight maternal deaths in the West African sub-region as a whole [3][4][5]. Abortion is legal only when done to save the life of a woman in Nigeria, which is restrictive by law. In fact, many abortions are performed by unskilled abortion care providers, as the following case reported shows.

Case report

A 20-year-old, single girl with no children was admitted to the accident and emergency department of Lagos University Teaching Hospital in January 2000 with a nine-hour history of protrusion of a mass from the vagina. The information reported here was obtained from her case notes and the operating theatre register.

Earlier that day she had had an attempted termination of a 16-week pregnancy by dilatation and curettage (D&C) at a private hospital. However, she became restless with the injection of an anaesthetic drug (ketamine), and an attempt at the passage of instruments into the vagina for the procedure led to a suspected uterine perforation. The procedure was subsequently abandoned and the patient was referred to our Gynaecological Emergency Centre. The patient, however, went home instead because of the fear of coming to a public institution.

At home, while eating, she developed a cough and with each coughing episode she noticed an increasing protrusion of a mass from her vagina. She was brought to the Gynaecological Emergency Centre with associated abdominal pain and mild bleeding from the vagina as well. She said she had had an induced abortion (at six weeks of pregnancy) the previous year without complications.

On examination, she was found to be mildly dehydrated and pale but with a normal pulse rate of 84 beats/min and blood pressure of 120/70 mmHg. Her abdomen was not distended, the Fundal height was 16-week size and the bowel sounds were absent. There were loops of gangrenous small intestine protruding from her vagina (Figure 1 ). A diagnosis of uterine perforation with herniation of the small intestine was made. She was resuscitated with intravenous fluids and antibiotics, and had an emergency exploratory laparotomy.

Fig. 1 Loops of gangrenous small intestine protruding from the vagina, 20-year-old girl, Lagos University Teaching Hospital, Nigeria.

At surgery, a perforation through the utero-vesical space was found with herniation of the small intestine through it. The uterus was still intact and no injury was seen. The gangrenous small bowel was reduced, i.e. returned to the abdominal cavity through the perforation, and a resection and anastomosis (excision and rejoining) was performed. The perforation in the utero-vesical space was repaired. While awaiting proper second trimester induction, the patient expelled the products of conception spontaneously three days post-operatively and an evacuation by manual vacuum aspiration was done. She was maintained on appropriate antibiotics, made a satisfactory recovery and was discharged two weeks post-admission. She was also given contraceptive counselling and referred to the Departmental Family Planning Clinic for services.

Comment

Unsafe abortion is fraught with many complications, including pelvic sepsis, septicaemia, haemorrhage, renal failure, uterine perforation and other genital tract injuries, gastro-intestinal tract injuries. Where emergency expert treatment for these is not available, death will result [6][7]. This case of induced abortion with bowel injury highlights the persisting problems of unsafe abortions in Nigeria. Bowel injury is a serious and life-threatening complication in a case such as this [6], though occurring in this girl in an unusual presentation. Complications such as this occur when abortion is badly performed, particularly by untrained personnel and in unhygienic conditions [7]. While a significant and increasing number of abortions are being performed by physicians, usually in private clinics and hospitals [2][8][9], these abortions must be done in secretive conditions and training for the doctors involved is often less than optimal or non-existent. This happens when the law is so restrictive, as is the case in Nigeria. This situation is exemplified by this case report, in which the provider attempted a second trimester termination using D & C, failed to take the patient directly to the referral centre or at least arrange for her immediate transfer, and then the patient was too frightened to come to a public hospital on referral.

The issue of abortion remains a delicate one in our country, presenting a complex moral and ethical dilemma. In all societies, however, no matter what the legal, moral or cultural status of abortion is, there are women who will seek to terminate an unwanted pregnancy [10]. While correct and consistent use of highly effective contraception will prevent most unwanted pregnancies and greatly reduce the need for abortion, it cannot eliminate this need [11][12], nor have most Nigerian women and men yet achieved this level of contraceptive use [13].

It is for reasons such as these and in order to prevent the serious morbidity reported here, which is so costly for women's health and for the health service itself, that many have advocated the need for reform of the current abortion law and policy, to ensure that safe abortion services are made available to all women in need, as well as training for abortion service providers [11][14]. Unsafe abortion procedures, untrained abortion service providers, restrictive laws and high morbidity and mortality from abortion tend to occur together [14]. It is therefore necessary to advocate for a review of the existing restrictive laws in Nigeria in order to reduce the high morbidity and mortality from unsafe abortion.