Post-abortion care services at Red Sea State - Sudan.

BACKGROUND: Although there are safe and effective methods of abortion, unsafe abortions still widely spread, mainly in underdeveloped countries.
OBJECTIVE: Study of post abortion care services at Red Sea State to address rate and utilization of post-abortion care package.
METHODS: This is a descriptive (observational hospital-based study), conducted at Port Sudan Maternity hospital (May 2018-May 2019). The sample included all patients with inevitable and incomplete miscarriage.
RESULTS: The total admissions to emergency in gynaecological department during the study period was 9525 cases, of them 1077 cases of abortion, hence the rate was 11.3%. Spontaneous onset occurred in 631 (58.6%) and induced in 446 (41.4%). Surprisingly very few surgical evacuations done in 2 (0.2%). 710 (66.1%) evacuated by Misoprostol and MVA done for 362 (33.7%). Patients who received family planning and counseling were 223 (20.7%).
CONCLUSION: in conclusion the rate of abortion was 11.3%, high incidence of induced abortion and high non-surgical evacuation. Utilization of care package is reasonable. Copyright:

Introduction

Miscarriage is spontaneous pregnancy loss before viability, abortion is responsible for 15% of pregnancy related morbidity.[1] Termination of an unwanted pregnancy by unauthorized person and in a place with minimum medical care standards is unsafe and may lead to maternal mortality or morbidity.[2] Safe or unsafe abortion is associated with many complications, About 46 million of abortions are induced every year.[3] unsafe counts about 20 million, 95% take place in the developing countries.[4] Unsafe abortion counts for almost 67,000 of pregnancy-related deaths every year.[5] Developing countries restricting legal abortion, which lead women's seeking clandestine procedures.[6] All complications almost wholly are preventable, post-abortion care (PAC) is an approach with curative and preventive health services, (PAC) post-abortion care includes five elements: treatment, family planning services, counseling, other reproductive and related health services, and community service provider cooperation.[7] This study will address the rate of abortion, immediate complications, methods of evacuation of safe and unsafe abortion and utilization of post-abortion care. MVA (manual vacuum aspiration) is recommended over dilation and curettage (D & C), and misoprostol is strongly recommended as a non-surgical substitute.[8] There is great progress in delivering legal and safe services as well as using long-acting contraception, like IUDs and implants.[9]

Subjects and Methods

This is a descriptive observational hospital-based study conducted in Port Sudan maternity hospital which provide tertiary care, during the period between May 2018 and May 2019.all patients attended to Gynecology causality with vaginal bleeding in early pregnancy except those diagnosed as ectopic pregnancy and threatened abortion. Total of 1077 cases fulfilled the inclusion criteria of the study. Data collected by direct interview using predesigned self-administered questionnaires during period of miscarriage and its complications. The analyzed by (SPSS), and results presented in table's graphs May 2019.

Results

The total admissions to emergency in gynecological department during the study period was 9525 cases, of them 1077 cases of abortion, hence the rate was 11.3%. All the cases from Red Sea State and managed at Port Sudan Maternity Hospital.

Table 1 illustrate methods of induction. Misoprostol used for 424 (39.4%), manipulation by foreign body 16 (1.5%), quinine 5 (0.5%) and herbal medicines 1 (0.1%). Also, spontaneous onset occurred in 631 (58.6%) and induced in 446 (41.4%).

Table 1

Shows the induction of abortion in the Red sea state - Sudan (n=1077)

Induction	n	%
Not induced	631	58.5
Manipulation foreign body	016	01.5
Drugs (misoprostol)	424	39.4
drug (quinine)	005	00.5
Herbal medicines	001	00.1
Total	1077	100.0

Table 2 shows distribution of the cases according to complications. No complications in 1052 (97.7%). Reported complications were septicemia 19 (1.8%), shock (hemorrhage) 4 (0.3%), uterine perforation 2 (0.2%) and no maternal death reported. Table 3 illustrate distribution of the cases according to types of family planning received. Patients who received counseling and family planning discharge were 223 (20.7%). Types included combined oral contraceptives 100 (44.8%), progesterone only pills 95 (42.6%), and intrauterine contraceptive device 28 (12.6%). Distribution of the cases according to type of evacuation. Out of 1074 evacuated cases, medical evacuation by misoprostol done for 710 (66.1%), MVA done for 362 (33.7%) and surgical evacuation (sharp curettage) done for 2 (0.2%) Figure 1.

Table 2

The complications of abortion in the Red sea state - Sudan (n=1077)

Complications	n	%
Shock (hemorrhagic)	004	00.3
Septicemia	019	01.8
Uterine perforation	002	00.2
No Complication	1052	97.7
Total	1077	100.0

Table 3

The family planning methods used in the Red sea state - Sudan (n=233)

FP	n	%
COC	100	44.8
IUCD	028	12.6
POP	095	42.6
Total	223	100.0

Figure 1

Shows the distribution of abortion according to type of evacuation in the Red sea state - Sudan (n = 1074)

Discussion

In this study, the rate of abortion was 11.3%. This is similar to other studies showed that Unsafe abortion accounts for an estimated 13%.[5]

Surprisingly we found that about 40% of the patient used method for induction of abortion, commonly misoprostol, foreign body, quinine and herbal medicines, to our knowledge no study addresses this. This practice may be explained by social stigma and legal issues.

Figure 1 illustrate very interesting results which denote improvement in our PAC service, hence 66.1% treated with misoprostol, 33.7% treated with MVA and only 0.2% require sharp evacuation, despite the fact that obtained from study in capital of Sudan 2009 which concluded that, the commonly used method of treatment among 726 is dilatation and curettage (D&C).[10] Also, in Pakistan, instrumentation of the uterus was the commonest method of induction, used in 65% of cases.[11] Whereas, another study In Kenya MVA or electronic vacuum aspiration (EVA) used as treatment modality in 65% of abortion.[12]

Our study revealed 2.3% complications, commonly septicemia, hemorrhage, and uterine perforation which was due to sharp evacuation; however, there is no maternal death and this is high than what been concluded by Singh, concluded that 5·7 per 1000 women in the developing countries admitted for treatment of complication of induced abortion yearly except China[13]

Regarding utilization of family planning, the patients who received family planning were 223 (20.7%), Although another study in Sudan concluded that family planning services counseling delivered to 301 lady (8.0%).[14] but Experts have stressed that post abortion package (counseling and family planning) must be given simultaneously in the same treatment place.[3]

Conclusion

We conclude that the rate of abortion was 11.3%, almost 50% of the cases was induced. The interesting conclusion is the low surgical evacuation. Also, utilization of PAC package is acceptable.

Key Messages

Expanding access to post-abortion care by implementing new canters in all maternity hospital and obstetrics and gynaecology departments with annually audit, will reduce morbidity and mortality from unsafe abortion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.