High severity of abortion complications in fragile and conflict-affected settings: a cross-sectional study in two referral hospitals in sub-Saharan Africa (AMoCo study).

BACKGROUND: Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR). METHODS: We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records' reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity. RESULTS: We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%). CONCLUSION: Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.

Provision of emergency obstetric care at secondary level in a conflict setting in a rural area of Afghanistan - is the hospital fulfilling its role?

BACKGROUND: Provision of Emergency Obstetric and Neonatal Care (EmONC) reduces maternal mortality and should include three components: Basic Emergency Obstetric and Neonatal Care (BEmONC) offered at primary care level, Comprehensive EmONC (CEmONC) at secondary level and a good referral system in-between. In a conflict-affected province of Afghanistan (Khost), we assessed the performance of an Médecins Sans Frontières (MSF) run CEmONC hospital without a primary care and referral system. Performance was assessed in terms of hospital utilisation for obstetric emergencies and quality of obstetric care. METHODS: A cross-sectional study using routine programme data (2013-2014). RESULTS: Of 29,876 admissions, 99% were self-referred, 0.4% referred by traditional birth attendants and 0.3% by health facilities. Geographic origins involved clustering around the hospital vicinity and the provincial road axis. While there was a steady increase in hospital caseload, the number and proportion of women with Direct Obstetric Complications (DOC) progressively dropped from 21% to 8% over 2 years. Admissions for normal deliveries continuously increased. In-hospital maternal deaths were 0.03%, neonatal deaths 1% and DOC case-fatality rate 0.2% (all within acceptable limits). CONCLUSIONS: Despite a high and ever increasing caseload, good quality Comprehensive EmONC could be offered in a conflict-affected setting in rural Afghanistan. However, the primary emergency role of the hospital is challenged by diversion of resources to normal deliveries that should happen at primary level. Strengthening Basic EmONC facilities and establishing an efficient referral system are essential to improve access for emergency cases and increase the potential impact on maternal mortality.

Care requirements for clients who present after rape and clients who presented after consensual sex as a minor at a clinic in Harare, Zimbabwe, from 2011 to 2014.

STUDY GOALS: To describe the differences between clients presenting after rape and clients who have consented to sex as a minor to an SGBV clinic in Harare, Zimbabwe, and how these differences affect their care requirements. BACKGROUND: Adolescents and adults presenting at the specialized Sexual and Gender Based Violence clinic in Harare are offered a standardised package of free medical and psychosocial care. Zimbabwe has an HIV prevalence of 14%, so prevention of HIV infection using PEP for those that present within 72 hours is a key part of the response. STI treatment, emergency contraceptive pills, referral for termination of pregnancy, psychological, social and legal support is also provided. METHODS: This is a retrospective descriptive study of routine programmatic data collected at the Edith Opperman polyclinic in Mbare SGBV clinic from 2011 to 2014. Chi-square tests and logistic regression were used to describe the different experiences and the differences in uptake of care between clients presenting for rape compared to those who consented to sex as a minor. RESULTS: During the study period a total of 3617 clients presented to the clinic. 2242 (62%) sought care after rape, 602 (17%) for having consented to sex as a minor and 395 (11%) for suspected sexual abuse. 1615 (45%) of people presenting were 12-15 year olds. Minors who consented to sex compared to survivors of rape were less likely to report within 72 hours- 156 (26%) vs 894 (40%) p<0.001; less likely to report that they delayed due to fear- 68 (17%) vs 472 (40%) p<0.001, less likely to have experienced accompanying violence- 9 (1%) vs 176 (8%) p<0.001 or physical trauma-34 (6%) vs 427 (19%) p<0.001; and less likely to display psychological symptoms at presentation 51 (8%) vs 411 (18%) p<0.001. Minors who consented to sex compared to those who were raped were less likely to start PEP if eligible-123 (80%) vs 751 (93%) p<0.001, less likely to take emergency contraceptives if eligible-125 (81%) vs 598 (88%) p<0.001, more likely to be pregnant- 132 (23%) vs 241 (15%) p<0.001; less likely to request a termination of pregnancy if pregnant-10 (8%) vs 74 (31%) p<0.001; and less likely to come for at least one follow up 281 (47%) vs 1304 (58%) p<0.001. CONCLUSION: The experiences of those who consent to sex as a minor and those that have experienced forced sex were very different. The standardised SGBV medical response does not fully meet the needs to protect minors who have consented to sex from HIV or unwanted pregnancies. Clients who present for having consented to sex as a minor might benefit more from being offered long-term family planning or being assessed as a sero-discordant couple rather than simply PEP and ECP as is relevant for clients who have been raped. More provision of health care is needed for minors to ensure they have access to enough information and protection from HIV, other STIs and unwanted pregnancy, before they decide to engage in sexual intercourse, rather than as an emergency at an SGBV clinic.

Dilemmas in Managing Pregnant Women With Ebola: 2 Case Reports.

We report 2 cases of Ebola viral disease (EVD) in pregnant women who survived, initially with intact pregnancies. Respectively 31-32 days after negativation of the maternal blood EVD-polymerase chain reaction (PCR) both patients delivered a stillborn fetus with persistent EVD-PCR amniotic fluid positivity.