Standardizing abortion research outcomes (STAR): Results from an international consensus development study.

OBJECTIVE: To develop a minimum data set, known as a core outcome set, for future abortion randomized controlled trials. STUDY DESIGN: We extracted outcomes from quantitative and qualitative systematic reviews of abortion studies to assess using a modified Delphi method. Via email, we invited researchers, clinicians, patients, and healthcare organization representatives with expertise in abortion to rate the importance of the outcomes on a 9-point Likert scale. After 2 rounds, we used descriptive analyses to determine which outcomes met the predefined consensus criteria. We finalized the core outcome set during a series of consensus development meetings. RESULTS: We entered 42 outcomes, organized in 15 domains, into the Delphi survey. Two-hundred eighteen of 251 invitees (87%) provided responses (203 complete responses) for round 1 and 118 of 218 (42%) completed round2. Sixteen experts participated in the development meetings. The final outcome set includes 15 outcomes: 10 outcomes apply to all abortion trials (successful abortion, ongoing pregnancy, death, hemorrhage, uterine infection, hospitalization, surgical intervention, pain, gastrointestinal symptoms, and patients' experience of abortion); 2 outcomes apply to only surgical abortion trials (uterine perforation and cervical injury), one applies only to medical abortion trials (uterine rupture); and 2 apply to trials evaluating abortions with anesthesia (over-sedation/respiratory depression and local anesthetic systemic toxicity). CONCLUSION: Using robust consensus science methods we have developed a core outcome set for future abortion research. IMPLICATIONS: Standardized outcomes in abortion research could decrease heterogeneity among trials and improve the quality of systematic reviews and clinical guidelines. Researchers should select, collect, and report these core outcomes in future abortion trials. Journal editors should advocate for core outcome set reporting.

A decade of progress providing safe abortion services in Ethiopia: results of national assessments in 2008 and 2014.

BACKGROUND: Ethiopia has one of the highest maternal mortality ratios in the world (420 per 100,000 live births in 2013), and unsafe abortion continues to be one of the major causes. To reduce deaths and disabilities from unsafe abortion, Ethiopia liberalized its abortion law in 2005 to allow safe abortion under certain conditions. This study aimed to measure how availability and utilization of safe abortion services has changed in the last decade in Ethiopia. METHODS: This paper draws on results from nationally representative health facility studies conducted in Ethiopia in 2008 and 2014. The data come from three sources at two points in time: 1) interviews with 335 health providers in 2008 and 822 health care providers in 2014, 2) review of facility logbooks, and 3) prospective data on 3092 women in 2008 and 5604 women in 2014 seeking treatment for abortion complications or induced abortion over a one month period. The Safe Abortion Care Model was used as a framework of analysis. RESULTS: There has been a rapid expansion of health facilities eligible to provide legal abortion services in Ethiopia since 2008. Between 2008 and 2014, the number of facilities reporting basic and comprehensive signal functions for abortion care increased. In 2014, access to basic abortion care services exceeded the recommended level of available facilities providing the service, increasing from 25 to 117%, with more than half of regions meeting the recommended level. Comprehensive abortion services increased from 20% of the recommended level in 2008 to 38% in 2014. Smaller regions and city administrations achieved or exceeded the recommended level of comprehensive service facilities, yet larger regions fall short. Between 2008 and 2014, the use of appropriate technology for conducting first and second trimester abortion and the provision of post abortion family planning has increased at the same time that abortion-related obstetric complications have decreased. CONCLUSION: Ten years after the change in abortion law, service availability and quality has increased, but access to lifesaving comprehensive care still falls short of recommended levels.

Changes in Morbidity and Abortion Care in Ethiopia After Legal Reform: National Results from 2008 and 2014.

CONTEXT: In Ethiopia, liberalization of the abortion law in 2005 led to changes in abortion services. It is important to examine how levels and types of abortion care-i.e., legal abortion and treatment of abortion complications-changed over time. METHODS: Between December 2013 and May 2014, data were collected on symptoms, procedures and treatment from 5,604 women who sought abortion care at a sample of 439 public and private health facilities; the sample did not include lower-level private facilities-some of which provide abortion care-to maintain comparability with the sample from a 2008 study. These data were combined with monitoring data from 105,806 women treated in 74 nongovernmental organization facilities in 2013. Descriptive analyses were conducted and annual estimates were calculated to compare the numbers and types of abortion care services provided in 2008 and 2014. RESULTS: The estimated annual number of women seeking a legal abortion in the types of facilities sampled increased from 158,000 in 2008 to 220,000 in 2014, and the estimated number presenting for postabortion care increased from 58,000 to 125,000. The proportion of abortion care provided in the public sector increased from 36% to 56% nationally. The proportion of women presenting for postabortion care who had severe complications rose from 7% to 11%, the share of all abortion procedures accounted for by medical abortion increased from 0% to 36%, and the proportion of abortion care provided by midlevel health workers increased from 48% to 83%. Most women received postabortion contraception. CONCLUSIONS: Ethiopia has made substantial progress in expanding comprehensive abortion care; however, eradication of morbidity from unsafe abortion has not yet been achieved.

The Estimated Incidence of Induced Abortion in Ethiopia, 2014: Changes in the Provision of Services Since 2008.

CONTEXT: In 2005, Ethiopia's parliament amended the penal code to expand the circumstances in which abortion is legal. Although the country has expanded access to abortion and postabortion care, the last estimates of abortion incidence date from 2008. METHODS: Data were collected in 2014 from a nationally representative sample of 822 facilities that provide abortion or postabortion care, and from 82 key informants knowledgeable about abortion services in Ethiopia. The Abortion Incidence Complications Methodology and the Prospective Morbidity Methodology were used to estimate the incidence of abortion in Ethiopia and assess trends since 2008. RESULTS: An estimated 620,300 induced abortions were performed in Ethiopia in 2014. The annual abortion rate was 28 per 1,000 women aged 15-49, an increase from 22 per 1,000 in 2008, and was highest in urban regions (Addis Ababa, Dire Dawa and Harari). Between 2008 and 2014, the proportion of abortions occurring in facilities rose from 27% to 53%, and the number of such abortions increased substantially; nonetheless, an estimated 294,100 abortions occurred outside of health facilities in 2014. The number of women receiving treatment for complications from induced abortion nearly doubled between 2008 and 2014, from 52,600 to 103,600. Thirty-eight percent of pregnancies were unintended in 2014, a slight decline from 42% in 2008. CONCLUSIONS: Although the increases in the number of women obtaining legal abortions and postabortion care are consistent with improvements in women's access to health care, a substantial number of abortions continue to occur outside of health facilities, a reality that must be addressed.

Costs of postabortion care in public sector health facilities in Malawi: a cross-sectional survey.

BACKGROUND: Health systems could obtain substantial cost savings by providing safe abortion care rather than providing expensive treatment for complications of unsafely performed abortions. This study estimates current health system costs of treating unsafe abortion complications and compares these findings with newly-projected costs for providing safe abortion in Malawi. METHODS: We conducted in-depth surveys of medications, supplies, and time spent by clinical personnel dedicated to postabortion care (PAC) for three treatment categories (simple, severe non-surgical, and severe surgical complications) and three uterine evacuation (UE) procedure types (manual vacuum aspiration (MVA), dilation and curettage (D&C) and misoprostol-alone) at 15 purposively-selected public health facilities. Per-case treatment costs were calculated and applied to national, annual PAC caseload data. RESULTS: The median cost per D&C case ($63) was 29% higher than MVA treatment ($49). Costs to treat severe non-surgical complications ($63) were almost five times higher than those of a simple PAC case ($13). Severe surgical complications were especially costly to treat at $128. PAC treatment in public facilities cost an estimated $314,000 annually. Transition to safe, legal abortion would yield an estimated cost reduction of 20%-30%. CONCLUSIONS: The method of UE and severity of complications have a large impact on overall costs. With a liberalized abortion law and implementation of induced abortion services with WHO-recommended UE methods, current PAC costs to the health system could markedly decrease.

ACCEPTABILITY OF THE INVOLVEMENT OF HEALTH EXTENSION WORKERS (HEWS) IN MEDICAL ABORTION (MA): THE PERSPECTIVES OF CLIENTS, SERVICE PROVIDERS AND TRAINED HEWS IN EAST SHOA AND ARSI ZONES, OROMIYA REGION, ETHIOPIA.

BACKGROUND: Unsafe abortion remains a significant contributor of maternal morbidity and mortality in Ethiopia and other developing countries. Involvement of community based health workers, health extension workers (HEWs) in Ethiopia, is a vital step in increasing access and utilization of medical abortion and related services. In order to engage HEWs, it is important to understand the attitude of women and service providers. OBJECTIVE: To explore the acceptability of involvement of HEWs in medical abortion by women who seek services, by abortion service providers, and assess willingness and confidence of HEWs. METHODS: An exploratory in-depth interview was conducted at three purposively selected health facilities in Ethiopia; namely Marie Stopes International (MSI) Adama clinic, MSI Asella clinic and Adama Government Health Centre from July-August, 2013. The interviews were transcribed verbatim and analysis was done using Atlas ti software. Themes were abstracted from coded text segments. The findings are presented using quotations, Atlas ti networks and queries. RESULTS: Thirty eight (26 eligibility, 12 follow up) women participated in the study and 9 HEWs and 7 service providers were interviewed. Almost all of the interviewed women, service providers and HEWs accepted HEWs involvement in medical abortion services. The HEWs expressed readiness and confidence. Concerns related to the involvement of HEWs included confidentiality, privacy, over dependence on abortion rather than preventing unwanted pregnancy, quality and poor referral system. CONCLUSIONS: Expansion of medical abortion services by involving HEWs can contribute to the reduction of abortion related morbidity and mortality. Concerns of the study population should be addressed by training HEWs for medical abortion, creating better awareness and advocacy among women and communities, addressing quality and referral issues with proper planning, implementing and monitoring of activities.

Unsafe abortion in Kenya: a cross-sectional study of abortion complication severity and associated factors.

BACKGROUND: Complications due to unsafe abortion cause high maternal morbidity and mortality, especially in developing countries. This study describes post-abortion complication severity and associated factors in Kenya. METHODS: A nationally representative sample of 326 health facilities was included in the survey. All regional and national referral hospitals and a random sample of lower level facilities were selected. Data were collected from 2,625 women presenting with abortion complications. A complication severity indicator was developed as the main outcome variable for this paper and described by women's socio-demographic characteristics and other variables. Ordered logistic regression models were used for multivariable analyses. RESULTS: Over three quarters of abortions clients presented with moderate or severe complications. About 65% of abortion complications were managed by manual or electronic vacuum aspiration, 8% by dilation and curettage, 8% misoprostol and 19% by forceps and fingers. The odds of having moderate or severe complications for mistimed pregnancies were 43% higher than for wanted pregnancies (OR, 1.43; CI 1.01-2.03). For those who never wanted any more children the odds for having a severe complication was 2 times (CI 1.36-3.01) higher compared to those who wanted the pregnancy then. Women who reported inducing the abortion had 2.4 times higher odds of having a severe complication compared to those who reported that it was spontaneous (OR, 2.39; CI 1.72-3.34). Women who had a delay of more than 6 hours to get to a health facility had at least 2 times higher odds of having a moderate/severe complication compared to those who sought care within 6 hours from onset of complications. A delay of 7-48 hours was associated with OR, 2.12 (CI 1.42-3.17); a delay of 3-7 days OR, 2.01 (CI 1.34-2.99) and a delay of more than 7 days, OR 2.35 (CI 1.45-3.79). CONCLUSIONS: Moderate and severe post-abortion complications are common in Kenya and a sizeable proportion of these are not properly managed. Factors such as delay in seeking care, interference with pregnancy, and unwanted pregnancies are important determinants of complication severity and fortunately these are amenable to targeted interventions.

The severity of abortion complications in Malawi.

OBJECTIVE: To assess the severity of abortion complications in Malawi and to determine associated risk factors. METHODS: Between July 20 and September 13, 2009, a cross-sectional survey was conducted at 166 facilities providing postabortion care services. Data were collected for all women with an incomplete, inevitable, missed, complete, or septic abortion. Weighted percentages were calculated to obtain national estimates. RESULTS: In total, 2067 women met the inclusion criteria. Estimates suggest that 80.9% of women who presented for postabortion care in Malawi in 2009 were married and 64.8% were from rural areas. One-quarter (27.4%) presented with severe or moderate morbidity. Sepsis (13.7%), retained products of conception (12.7%), and fever (12.3%) were the most common complications. The case fatality rate was 387 deaths per 100 000 postabortion care procedures. Women with severe or moderate complications were significantly more likely to be from rural areas than from urban areas; to have reported interfering with their pregnancy; and to be separated, divorced, or widowed than to be single. CONCLUSION: In 2009, many women seeking postabortion care in Malawi presented with complications. Advocacy is needed to influence policies that will allow expanded access to safe abortion services for women of all ages and in all areas.

The incidence of induced abortion in Malawi.

CONTEXT: Abortion is legally restricted in Malawi, and no data are available on the incidence of the procedure. METHODS: The Abortion Incidence Complications Methodology was used to estimate levels of induced abortion in Malawi in 2009. Data on provision of postabortion care were collected from 166 public, nongovernmental and private health facilities, and estimates of the likelihood that women who have abortions experience complications and seek care were obtained from 56 key informants. Data from these surveys and from the 2010 Malawi Demographic and Health Survey were used to calculate abortion rates and ratios, and rates of pregnancy and unintended pregnancy. RESULTS: Approximately 18,700 women in Malawi were treated in health facilities for complications of induced abortion in 2009. An estimated 67,300 induced abortions were performed, equivalent to a rate of 23 abortions per 1,000 women aged 15-44 and an abortion ratio of 12 per 100 live births. The abortion rate was higher in the North (35 per 1,000) than in the Central region or the South (20-23 per 1,000). The unintended pregnancy rate in 2010 was 139 per 1,000 women aged 15-44, and an estimated 52% of all pregnancies were unintended. CONCLUSIONS: Unsafe abortion is common in Malawi. Interventions are needed to help women and couples avoid unwanted pregnancy, reduce the need for unsafe abortion and decrease maternal mortality.

Meeting the need for safe abortion care in Ethiopia: results of a national assessment in 2008.

Complications of an unsafe abortion are a major contributor to maternal deaths and morbidity in Africa. When abortions are performed in safe environments, such complications are almost all preventable. This paper reports results from a nationally representative health facility study conducted in Ethiopia in 2008. The safe abortion care (SAC) model, a monitoring approach to assess the amount, distribution, use and quality of abortion services, provided a framework. Data collection included key informant interviews with 335 health care providers, prospective data on 8911 women seeking treatment for abortion complications or induced abortion and review of facility logbooks. Although the existing hospitals perform most basic abortion care functions, the number of facilities providing basic and comprehensive abortion care for the population size fell far short of the recommended levels. Almost one-half (48%) of women treated for obstetric complications in the facilities had abortion complications. The use of appropriate abortion technologies in the first trimester and the provision of post-abortion contraception overall were reasonably strong, especially in private sector facilities. Following abortion law reform in 2005 and subsequent service expansion and improvements, Ethiopia remains committed to reducing complications from an unsafe abortion. This study provides the first national snapshot to measure changes in a dynamic abortion care environment.

Attitudes toward abortion in Zambia.

Despite Zambia's relatively progressive abortion law, women continue to seek unsafe, illegal abortions. Four domains of abortion attitudes - support for legalization, immorality, rights, and access to services - were measured in 4 communities. A total of 668 people were interviewed. Associations among the 4 domains were inconsistent with expectations. The belief that abortion is immoral was widespread, but was not associated with lack of support for legalization. Instead, it was associated with belief that women need access to safe services. These findings suggest that increasing awareness about abortion law in Zambia may be important for encouraging more favorable attitudes.

Clinical diagnosis of completeness of medical abortion by nurses: a reliability study in Mozambique.

BACKGROUND: The provision of medical abortion continues to rely on routine use of ultrasound to confirm expulsion of pregnancy. However, the absence of ultrasound in most of the health facilities in developing countries and the additional training required to enable providers to use ultrasound is often prohibitive. The purpose of this study was to compare clinical history and physical examination with ultrasound in confirming completion of abortion. STUDY DESIGN: A total of 718 women consented for medical abortion with misoprostol and were assessed for pregnancy expulsion by nurses and gynecologists. Nurses used history and physical examination while gynecologists used ultrasound to establish their diagnoses. RESULTS: Nurses' clinical diagnoses for complete abortion, incomplete abortion and ongoing pregnancy were 83% (SE 0.01), 15% (SE 0.01) and 2% (SE 0.01), respectively. When gynecologists used ultrasound, the diagnoses for complete abortion, incomplete abortion, an ongoing pregnancy were 80% (SE 0.01), 17% (SE 0.01) and 3% (SE 0.01), respectively. Overall, nurses agreed with gynecologist diagnoses in 84% of cases, with a κ coefficient of 0.49 (SE 0.06) and chance-corrected first-order agreement (AC(1)) of 0.81 (SE 0.02). Agreement was very high for the diagnosis of complete abortion (AC(1) 0.89; SE 0.02), while it was moderate for ongoing pregnancy (AC(1) 0.58; SE 0.22) and incomplete abortion (AC(1) 0.45; SE 0.08). CONCLUSIONS: Clinical history and physical examination alone, without the use of ultrasonography, are effective for the determination of successful pregnancy expulsion. However, greater emphasis is required on the clinical identification of ongoing pregnancy during any training of providers.

A strategic assessment of unsafe abortion in Malawi.

As part of efforts to achieve Millennium Development Goal 5--to reduce maternal mortality by 75% and achieve universal access to reproductive health by 2015--the Malawi Ministry of Health conducted a strategic assessment of unsafe abortion in Malawi. This paper describes the findings of the assessment, including a human rights-based review of Malawi's laws, policies and international agreements relating to sexual and reproductive health and data from 485 in-depth interviews about sexual and reproductive health, maternal mortality and unsafe abortion, conducted with Malawians from all parts of the country and social strata. Consensus recommendations to address the issue of unsafe abortion were developed by a broad base of local and international stakeholders during a national dissemination meeting. Malawi's restrictive abortion law, inaccessibility of safe abortion services, particularly for poor and young women, and lack of adequate family planning, youth-friendly and post-abortion care services were the most important barriers. The consensus reached was that to make abortion safe in Malawi, there were four areas for urgent action--abortion law reform; sexuality education and family planning; adolescent sexual and reproductive health services; and post-abortion care services.

Choosing early pregnancy termination methods in Urban Mozambique.

Little is known about who chooses medication abortion with misoprostol and why. Women seeking early abortion in 5 public hospitals in Maputo, Mozambique were recruited in 2005 and 2006 to explore decision-making strategies, method preferences and experiences with misoprostol and vacuum aspiration for early abortion. Client screenings (n=1799), structured clinical surveys (n=837), in-depth exit interviews (n=70), and nurse focus groups (n=2) were conducted. Triangulation of qualitative and quantitative data revealed seemingly contradictory findings. Choice of method reflected women's heightened concerns about privacy, pain, quality of home support, HIV infection risk, sexuality, and safety of research participation. Urban Mozambican women are highly motivated to find early pregnancy termination techniques that they deem socially and clinically low-risk. Although 42% found vaginal misoprostol self-administration challenging and 25% delayed care for over a week to amass funds for user fees, almost all (96%) reported adequate preparation and comfort with home management. Women reported satisfaction with all methods and quality of care, even if the initial method failed or pain management or postabortion contraception were not offered. A more nuanced understanding of what women value most can yield service delivery models that are responsive and effective in reducing maternal death and disability from unsafe abortion.

Caring for women with abortion complications in Ethiopia: national estimates and future implications.

CONTEXT: Ethiopia liberalized its abortion law in 2005, primarily to reduce the incidence of unsafe abortion. However, little is known about the current extent and consequences of unsafe abortion. METHODS: Data were collected in 2007-2008 on 1,932 women seeking postabortion care at a nationally representative sample of 344 public and private health facilities. In addition, staff respondents at 337 facilities provided information on their facility's services and caseload. These data were used to examine patterns of abortion-related morbidity and treatment and to generate national estimates. RESULTS: Almost 58,000 women sought care for complications of induced or spontaneous abortion in 2008. Three-quarters of the women received care in government facilities. Forty-one percent had moderate or severe morbidity, such as signs of infection, that were likely related to an unsafe abortion. Seven percent of all women had signs of a mechanical injury or a vaginally inserted foreign body. More than 13,000 women seeking postabortion care required a hospital stay of at least 24 hours. The case fatality rate among women seeking postabortion care in public hospitals, where the most serious complications were seen, was 628 per 100,000. CONCLUSIONS: Postabortion care and safe abortion services should be further expanded and strengthened to make these services more accessible and affordable, which in turn may ease the financial burden on hospitals and allow the resources currently required for postabortion care to be used for other health needs. Ensuring that all women know that safe abortion is available and legal for many indications will further reduce morbidity from unsafe abortions.

The estimated incidence of induced abortion in Ethiopia, 2008.

CONTEXT: Unsafe abortion is an important health problem in Ethiopia; however, no national quantitative study of abortion incidence exists. In 2005, the penal code was revised to broaden the indications under which induced abortion is legal. It is important to measure the incidence of legal and illegal induced abortion after the change in the law. METHODS: A nationally representative survey of a sample of 347 health facilities that provide postabortion or safe abortion services and a survey of 80 professionals knowledgeable about abortion service provision were conducted in Ethiopia in 2007-2008. Indirect estimation techniques were applied to calculate the incidence of induced abortion. Abortion rates, abortion ratios and unintended pregnancy rates were calculated for the nation and for major regions. RESULTS: In 2008, an estimated 382,000 induced abortions were performed in Ethiopia, and 52,600 women were treated for complications of such abortions. There were an estimated 103,000 legal procedures in health facilities nationwide--27% of all abortions. Nationally, the annual abortion rate was 23 per 1,000 women aged 15-44, and the abortion ratio was 13 per 100 live births. The abortion rate in Addis Ababa (49 per 1,000 women) was twice the national level. Overall, about 42% of pregnancies were unintended, and the unintended pregnancy rate was 101 per 1,000 women. CONCLUSIONS: Unsafe abortion is still common and exacts a heavy toll on women in Ethiopia. To reduce rates of unplanned pregnancy and unsafe abortion, increased access to high-quality contraceptive care and safe abortion services is needed.

Who is excluded when abortion access is restricted to twelve weeks? Evidence from Maputo, Mozambique.

In Mozambique, since 1985, induced abortion services up to 12 weeks of pregnancy are performed in the interest of protecting women's health. We asked whether any women were being adversely affected by the 12-week limit. A retrospective record review of all 1,734 pregnant women requesting termination of pregnancy in five public hospitals in Maputo in 2005-2006 revealed that it tended to be those who were younger and poorer, with lower levels of education, literacy and formal employment who were coming for abortions after 12 weeks. Countries such as Mozambique that endeavor to enhance equality, equity and social justice must consider the detrimental effect of narrow gestational limits on its most vulnerable citizens and include second trimester abortions. We believe the 12-week restriction works against efforts to reduce maternal deaths due to unsafe abortion in the country.

No evidence for prolonged excretion of polioviruses in persons with residual paralytic poliomyelitis in Ethiopia, Pakistan and Guatemala.

Persons who have developed acute flaccid paralysis following infection with wild-type polioviruses or vaccine-associated paralytic poliomyelitis usually excrete polioviruses for only a few weeks. However, some patients with paralytic poliomyelitis have had prolonged excretion of polioviruses for periods of up to 10 years after onset of disease. Most prolonged excretors have been identified in industrialized countries. We studied 348 patients 2-28 years old in Ethiopia, Pakistan and Guatemala with residual paralytic poliomyelitis to determine if they had IgA or IgG deficiency or persistent poliomyelitis excretion at least 1 year after onset of disease. None of the 348 affected individuals had IgG deficiency or persistent poliovirus excretion. One child had borderline low serum IgA concentration. Since we did not study children under 2 years of age, persons born with IgG deficiency disorders may have died in developing countries where replacement immunoglobulin therapy is not readily available. Nevertheless, persistent poliovirus excretion among persons 2 years of age and older with residual paralytic poliomyelitis is uncommon in developing countries.

The magnitude of abortion complications in Kenya.

OBJECTIVE: To estimate and describe the magnitude of abortion complications presenting at public hospitals in Kenya. DESIGN: Cross-sectional descriptive study. SETTING: Hospital-based. Population Records of all women presenting prior to 22 weeks of gestation with abortion-related complications at selected hospitals during a three-week study period. All public tertiary and provincial hospitals were included; stratified random sampling was employed to select a subset of 54 district hospitals nationwide. METHODS: Data collectors identified 809 patients with abortion complications on all hospital wards and completed a standardised questionnaire for each by extracting information from the patient's hospital record. MAIN OUTCOME MEASURES: Incidence, aetiology, morbidity and mortality of abortion complications. RESULTS: Most women (80%) presented with incomplete abortion. Approximately 34% of the women had reached the second trimester of pregnancy. Adolescents (14-19 years old) accounted for approximately 16% of the study sample. Manual vacuum aspiration was used to manage 80% of first trimester cases. The projected annual number of women with abortion complications admitted to public hospitals in Kenya is 20,893. The case fatality rate was estimated to be 0.87% (95% CI 0.71-1.02%), so an estimated 182 (95% CI 148-213) of these women die annually. The annual incidence of incomplete abortion and other abortion-related complications per 1000 women aged 15 to 49 years is projected to be 3.03. CONCLUSIONS: The high rate of abortion-related morbidity and mortality documented in the study highlights the critical need to address the issue of unsafe abortion in Kenya.

An assessment of abortion services in public health facilities in Mozambique: women's and providers' perspectives.

Complications of unsafe abortion contribute to high maternal mortality and morbidity in Mozambique. In 2002, the Ministry of Health conducted an assessment of abortion services in the public health sector to inform efforts to make abortion safer. This paper reports on interviews with 461 women receiving treatment for abortion-related complications in 37 public hospitals and four health centres in the ten provinces of Mozambique. One head of both uterine evacuation and contraceptive services at each facility was also interviewed, and 128 providers were interviewed on abortion training and attitudes. Women reported lengthy waiting times from arrival to treatment, far longer than heads of uterine evacuation services reported. Similarly, fewer women reported being offered pain medication than head staff members thought was usual. Less than half the women said they received follow-up care information, and only 27% of women wanting to avoid pregnancy said they had received a contraceptive method. Clinical procedures such as universal precautions to prevent infection were less than adequate, in-service training was less than comprehensive in most cases, and few facilities reviewed major complications or deaths. Use of dilatation and curettage was far more common than medical or aspiration abortion methods. Current efforts by the Ministry to improve abortion care services have focused on training of providers in all these matters and integration of contraceptive provision into post-abortion care.