Unsafe Abortion - Even Now

Illegal abortions are performed much more frequently in India with their disastrous results even today inspite of liberalisation 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.

INTRODUCTION

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

CASE REPORT

CASE 1

Gravida two, Para one, Abortion zero, Living one with three months of Amenorrhoea underwent first trimester induced abortion by suction and evacuation. The induced abortion was performed by a doctor without any training in midwifery an family planning. During the procedure uterine perforation and small bowel injury occurred. This injury was sustained by perforation of uterus by suction cannula and the bowel was pulled out by suction followed by use of ovum forceps. After realisation of the complication, the bowel was reposited through the uterine perforation into the peritoneal cavity by ovum forceps. Patient was transferred to a local civil hospital. Patient was brought to KEM Hospital on day 3 in a state of shock with a intraperitoneal drain in place draining purulent fluid, the drain was placed at the local civil hospital under local anaesthesia. Exploratory Laparotomy was performed. Uterus showed a right isthmic uterine perforation of 2 cm size. Uterus was gangre nous, small bowel showed extensive injury from one foot distal to duodeno-jejunal junction to lower ileum. Except for a small part of proximal jejunum, the rest of the small bowel appeared like a snake peeled of its skin i.e. the serosa of the bowel was peeled of the bowel and crumpled towards the proximal normal appearing jejunum. The mesentery was torn. The small bowel showed a single perforation in terminal ileum. Total abdominal hysterectomy with bilateral salpingo-oophorectomy and small bowel resection and removal of caecum with jejunostomy and ascending colon stoma performed. Eight weeks later jejuno - colic anastomosis was done. Patient survived and went home. At follow up examination, one month later, patient was doing well.

CASE 2

Gravida four, Para three, Living three with two months amenorrhoea underwent first trimester induced abortion by suction and evacuation.

Induced abortion was performed by doctor without any training in midwifery and family planning and send home. Patient developed vomiting and severe pain in abdomen on the next day. She presented to KEM Hospital more than 30 hours after the induced abortion with septicaemia, peritonitis, acute renal failure and Disseminated Intravascular Coagulopathy. Patient expired in a short period after admission. Post mortem examination revealed uterine perforation with peritonitis and evidence of septicaemia and DIC in various organs. No evidence of intestinal injury.

DISCUSSION

The term "unsafe abortion" proposed by the World Health Organisation (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.[1]

Unsafe abortions are performed 15-20 times more oftener 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 gynaecologists who do not wish to disclose these procedures for socio-economic and legal reasons.[1] 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.[2]

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.[2]

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).[3]

In a series of 950 septic abortions, 6.47 per cent i.e. 64 per 1000 cases died (Rao, 1971). The common causes of death are peritonitis, septicaemia, endotoxic shock, haemorrhage and tetanus.[4] The first patient in our 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 duodeno - jejunal 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.[1]

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 upto 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.[5]

A variety of induced abortion services are available in Asian countries and these may be obtained from 1. Government hospitals and centres, 2. Municipal hospitals and maternity homes, 3. Non-Government organisations (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 centres. It is important to understand that establishment of good abortion services on a completely free basis is a cost benefit measure (Soonawala, 1986).[6]

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. (Damey, 1986).7 dures safely. (Damey, 1986).[7]

Many of the General practitioners or Primary Health Centre (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 Centre, 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).[8]

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).[9]

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 (Henshaw, 1990). 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.[10]

REFERENCES

1.Chaudhuri SK. Practice of Fertility Control, A Comprehensive textbook 4th edition, New Delhi. BI Churchill Livingstone Pvt. Ltd. 1996; 220-52

2.World Health Organisation. Abortion. 2nd edition : Geneva : World Health Organisation. 1994.

3.Indian Council of Medical Research (ICMR). Illegal abortion in rural areas : A task force study; Indian Council of Medical Research, New Delhi. 1989.

4.Rao KB. Social and Clinical aspects of Septic Abortion. J Obst Gynaec India 1971; 21 : 644.

5.Ratnam SS, Bhasker Rao K, Arulkumaran S. Obstetrics and Gynaecology for Postgraduates. 1st edition. Orient Longman Ltd. 1992; 1 : 174-86.

6.Soonawala RP. Induced abortion services in Asia. In Landy U and Ratnam SS (eds). Prevention and treatment of Contraception failure, New York : Plenum Press. 1986; 187-89.

7.Darney PD. Training physicians in elective abortion techniques in the United States. In : Landy U and Ratnam SS (eds). Prevention and treatment of Contraceptive Failure. New York : Plenum Press. 1986; 133-40.

8.Ministry of Health and Family Welfare, Government of India. Family Welfare programme in India, Year Book 1988-1989. Government of India. 1990.

9.Ministry of Health and Family Planning, Government of India. Medical Termination of Pregnancy Act, 1971. 34 of 1971, 3-6 (iii) Amended 1972 New Delhi.

10.Henshaw SK. Induced abortion : a world review - 1990. Family Planning Persp. 1990; 22 (2) : 76-89.