Post on 13-Nov-2014
PUBLIC HEALTH ASPECTS OF PUBLIC HEALTH ASPECTS OF ABORTION:ABORTION:
AN OVERVIEWAN OVERVIEW
ByBy
Prof F. E. OkonofuaProf F. E. OkonofuaProvostProvost
College of Medical SciencesCollege of Medical SciencesUniversity of BeninUniversity of Benin
Abortion is the loss of pregnancy Abortion is the loss of pregnancy before it has reached stabilitybefore it has reached stability
Two types:Two types: Spontaneous Spontaneous Induced Induced
Estimates of AbortionEstimates of Abortion
1.1. Spontaneous Abortion – Estimates are Spontaneous Abortion – Estimates are unknown, because many are non-clinical unknown, because many are non-clinical abortionsabortions
2.2. Induced AbortionInduced AbortionDeveloped Countries Developed Countries -- 500,000500,000Developing Countries Developing Countries -- 18,400,00018,400,000Total (World)Total (World) -- 19 million 19 million Africa Africa -- 4.2 million4.2 millionNigeria Nigeria -- 610,000610,000
Impact of induced Abortion Impact of induced Abortion Number of Number of % of all % of all
maternal deaths maternal deaths maternal maternal deathsdeaths
From AbortionFrom Abortion
World World 67,90067,900 1313
Developed countries Developed countries 300300 1414
Developing Countries Developing Countries 67,50067,500 1313
Africa Africa 29,80029,800 1212
Nigeria Nigeria *20,000*20,00040*40*
Clinical Aspects of Clinical Aspects of Spontaneous AbortionSpontaneous Abortion
Spontaneous AbortionSpontaneous Abortion
Threatened AbortionThreatened Abortion Inevitable AbortionInevitable Abortion (including belighted ovum and (including belighted ovum and
missed missed abortion)abortion)
Incomplete AbortionIncomplete Abortion Complete Complete
Abortion Abortion
Threatened AbortionThreatened Abortion
Mild to moderate vaginal bleeding Mild to moderate vaginal bleeding Uneffaced and undilated cervixUneffaced and undilated cervix No abdominal pain No abdominal pain Fetus often viable Fetus often viable Conservative management Conservative management
Inevitable Abortion Inevitable Abortion
1.1. Blighted ovumBlighted ovum
2.2. Severe effacement and dilatation of Severe effacement and dilatation of the cervix, with or without passage the cervix, with or without passage of products of conception of products of conception
3.3. Death and retention of the fetus Death and retention of the fetus between 12 and 28 weeks (missed between 12 and 28 weeks (missed abortion)abortion)
Treatment of Inevitable Treatment of Inevitable Abortion Abortion
1.1. D&C versus MVAD&C versus MVA
2.2. MisoprostolMisoprostol
-- all stages, including all stages, including blighted ovumblighted ovum
Aetiology of Recurrent Aetiology of Recurrent AbortionAbortion
1.1. Cervical Incompetence Cervical Incompetence 2.2. Maternal illnesses – hypo or Maternal illnesses – hypo or
hyperthyroidism diabetes mellitus, hyperthyroidism diabetes mellitus, cardiovascular diseases cardiovascular diseases
3.3. Materno-fetal infections (toxoplasmosis, Materno-fetal infections (toxoplasmosis, Listeria monocytogene, rubella, Listeria monocytogene, rubella, cytomegalovirus, herpes simplex virus, cytomegalovirus, herpes simplex virus, brucella, Chlamydia, ureaplasma brucella, Chlamydia, ureaplasma urealyticum, T-strain mycoplasma)urealyticum, T-strain mycoplasma)
4.4. Endocrine factors – polycystic ovarian Endocrine factors – polycystic ovarian disease, luteal phase defect disease, luteal phase defect
5.5. Chromosomal anomalies Chromosomal anomalies 6.6. Immunological incompatibilityImmunological incompatibility
Investigation of Recurrent Investigation of Recurrent AbortionAbortion
1.1. Detailed History and physical examination Detailed History and physical examination 2.2. Hormone AssayHormone Assay3.3. Thyroid, renal & liver function tests Thyroid, renal & liver function tests 4.4. Glucose tolerance testsGlucose tolerance tests5.5. HSGHSG6.6. Ultrasound scan Ultrasound scan 7.7. SLE Lupus anti-coagulant test SLE Lupus anti-coagulant test 8.8. Anti-cardiolipin antibodies Anti-cardiolipin antibodies 9.9. Anti-nuclear factor Anti-nuclear factor 10.10. Anti-thyroid antibodies Anti-thyroid antibodies 11.11. Blood grouping Blood grouping 12.12. HLA typing in both partners HLA typing in both partners
Treatment of Recurrent Treatment of Recurrent Abortion Abortion
Treatment of underlying medical Treatment of underlying medical conditions conditions
Progesterone vaginal pressaries Progesterone vaginal pressaries MyomectomyMyomectomy Cervical cerclageCervical cerclage
-- Lash & Lash procedureLash & Lash procedure-- Shirodkar’s techniqueShirodkar’s technique-- MacDonald's techniqueMacDonald's technique
Induced Abortion Induced Abortion
Induced Abortion is done in all societies Induced Abortion is done in all societies and in all culturesand in all cultures
The issues is whether it is safe or unsafe The issues is whether it is safe or unsafe Induced abortion tends to be safe in Induced abortion tends to be safe in
countries where abortion is legal and countries where abortion is legal and unsafe in countries where abortion is unsafe in countries where abortion is restrictive and legalrestrictive and legal
Abortion tends to be safe in developed Abortion tends to be safe in developed countries and unsafe in developing countries and unsafe in developing countries countries
Patterns of Abortion Law in Patterns of Abortion Law in Africa Africa CountriesCountries
No of CountriesNo of Countries1.1. Abortion to save life of Abortion to save life of pregnant woman only pregnant woman only 24242.2. Abortion to preserve the life or health of a woman Abortion to preserve the life or health of a woman 9 9
3.3. To save her life and in cases of rape To save her life and in cases of rape 224.4. To preserve her life or health in cases of To preserve her life or health in cases of
contraceptive failure contraceptive failure 115.5. In cases of pregnancy resulting from rape and In cases of pregnancy resulting from rape and
incest – and fetal defect & to preserve her life & health incest – and fetal defect & to preserve her life & health 99
6.6. Additional indication of socioeconomic hardshipAdditional indication of socioeconomic hardship(Zambia)(Zambia) 11
7.7. Additional indication of a woman who is too young orAdditional indication of a woman who is too young or mentally unable to care for a child (Ethiopia) mentally unable to care for a child (Ethiopia) 1188 On request (Cape Verde, South Africa & Tunisia) On request (Cape Verde, South Africa & Tunisia) 33
TOTALTOTAL 5353
Why Women have Unwanted Why Women have Unwanted Pregnancy and Seek Abortion Pregnancy and Seek Abortion
They are too young or want postpone child They are too young or want postpone child bearing bearing
They want no more children They want no more children They cannot afford to raise a child They cannot afford to raise a child They are unmarried or still in school They are unmarried or still in school Their partners does not want the pregnancy Their partners does not want the pregnancy
or there is a problem with relationship or there is a problem with relationship They become pregnant due to rape or incestThey become pregnant due to rape or incest
Determinants of unwanted Determinants of unwanted Pregnancy and Unsafe AbortionPregnancy and Unsafe Abortion Young maternal age Young maternal age The role of women education The role of women education Pattern of contraceptive use Pattern of contraceptive use Religion Religion Abortion laws Abortion laws Provider attitude and training Provider attitude and training Use of outdated abortion methods and Use of outdated abortion methods and
technology technology Economic and geographic inequality Economic and geographic inequality
Complications of Induced Complications of Induced Abortion Abortion
Immediate Immediate
-- Occurring during or within Occurring during or within 48 48 hours hours
LateLate
-- Occurring later, especially Occurring later, especially after 48 after 48 hours hours
Early Complications of Induced Early Complications of Induced AbortionAbortion
Haemorrhage Haemorrhage Damage to adjacent organs – Damage to adjacent organs –
perforated uterus perforated uterus Sepsis (Septic abortion)Sepsis (Septic abortion)- Gram negative septicaemia Gram negative septicaemia
Treatment of Early Treatment of Early Complications of Induced Complications of Induced
Abortion Abortion 1.1. Intravenous infusion and/or blood Intravenous infusion and/or blood
transfusion transfusion
2.2. Blood spectrum antibiotics Blood spectrum antibiotics
3.3. Evacuation of retained products of Evacuation of retained products of conception (MVA)conception (MVA)
4.4. Laparotomy Laparotomy
Late complications of induced Late complications of induced Abortion Abortion
1.1. Chronic pelvic inflammatory diseaseChronic pelvic inflammatory disease
2.2. Ectopic pregnancy Ectopic pregnancy
3.3. Cervical Incompetence Cervical Incompetence
4.4. Asherman syndrome Asherman syndrome
Regimen for Safe Practice of Regimen for Safe Practice of Abortion Abortion
AA 11stst seven weeks seven weeks Mifepristone – misoprostol Mifepristone – misoprostol Misoprosotol alone Misoprosotol alone MVAMVA D & CD & C
B B 8 – 14 weeks 8 – 14 weeks Misoprostol – MVA Misoprostol – MVA Misoprostol – D & CMisoprostol – D & C
C C After 14 weeks After 14 weeks Mifepristone – misoprostol Mifepristone – misoprostol Repeated doses of misoprostol Repeated doses of misoprostol
Different Perspectives of Different Perspectives of Abortion Abortion
Abortion Abortion -- a public health issue a public health issue Abortion Abortion -- a gender issue a gender issue Abortion Abortion -- a rights issue a rights issue
-- right to life right to life -- right to health, reproductive right to health, reproductive
health and family planning health and family planning -- right to be free from right to be free from
discrimination discrimination -- right to liberty & security of right to liberty & security of
persons persons -- right to scientific progress right to scientific progress
AbortionAbortion - - a social and economic justice a social and economic justice issue issue
Prevention of Unsafe Prevention of Unsafe Abortion Abortion
AA Primary Prevention Primary Prevention -- sexuality education sexuality education -- promotion of contraception promotion of contraception
BB Secondary Prevention Secondary Prevention - provision of counseling to women with - provision of counseling to women with unwanted pregnancies unwanted pregnancies -- Liberation of abortion laws Liberation of abortion laws -- Increasing women’s access to safe Increasing women’s access to safe abortion abortion services services
CC Tertiary Prevention Tertiary Prevention -- Post abortion Care (PAC) at all levels Post abortion Care (PAC) at all levels -- In-services and pre-service training of In-services and pre-service training of providers providers -- Decentralization of PAC Decentralization of PAC
Thank youThank you