Abortion in a Rural Setting in Uganda: Morbidity, Mortality and Management

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS Unwanted pregnancy and unsafe abortion continue to be a major public health problem in Uganda. This study has demonstrated that the problem of abortion is still on the increase particularly among young women. A variety of demographic and socioeconomic factors – poverty and hardship, earlier start of sexual relations, shifts from rural to urban settings, influence of the media and limited accessibility and availability of effective contraception have contributed to the increase in premarital sexual activity and early pregnancy. Information about sexuality, safe sexual practices and contraception is often lacking. Responding to the needs of young women, particularly adolescents becomes difficult. This has resulted in many unintended pregnancies, a proportion of which have been terminated by unsafe abortion because of the legal restrictions. Other young women have had no other option than to continue the pregnancies – with all the attendant social and educational consequences. The study has filled a critical gap in knowledge regarding abortion complications presenting at Soroti Referral Hospital despite the limitations of projecting the incidence of abortion complications using hospital-based data. The results of the study are indeed a proof to the opinion that abortion is a common and increasing problem in rural areas too. The morbidity and mortality levels related to abortion which have been revealed by this study call for a concerted effort in prevention of unintended pregnancies, and unsafe abortion. This should be made a high priority if the goal of improving women’s reproductive health is to be achieved. It will remain important to study and monitor unsafe abortion so that trends can be assessed, efforts to prevent unintended pregnancy evaluated, and preventable causes of morbidity and mortality associated with abortion identified and reduced. The problem of abortion in Uganda is mainly linked to limited access to family planning services and lack of reliable information about modern contraception. A simple answer to the issue of unsafe abortion would be to guarantee universal access and availability of family planning information, education and services for all eligible couples and individuals, including sexually active adolescents. Effective sex education programmes which target teenagers in-and-out of school should be instituted, and must include correct information about reproduction and contraception. Dissemination of reliable information to even the most distant areas of the districts remain the sole responsibility of the district directorates of health and the health sub-districts in light of the decentralization policy on health services. In addition, all health centres should be equipped with adequate stocks of modern contraceptives if they have trained staff who can offer the services. The methods should be responsive to the needs and preferences of clients. Prevention of repeat abortions through provision of compassionate counseling and a range of contraceptive methods to women treated for abortion-related complications is paramount. The hospital should eliminate the administrative and physical separation between emergency treatment of abortion complications and family planning services. Many women expressed the desire to receive family planning counseling or methods after being treated for abortion complications. However, the fact that a woman had to get dressed, walk a cross a courtyard to the family planning clinic, check in, wait to be seen and undergo another examination impedes the provision of postabortion family planning. Many women – particularly those who were weak, in pain or emotionally drained – decided to go home instead of enduring this time-consuming and sometimes intimidating process. Starting this service in the gynaecological ward will be a step forward towards prevention of unintended pregnancies and unsafe abortion. The high prevalence of abortion complications in the hospital which is relatively understaffed overwhelms services. There are more patients than staff can treat in a reasonable time. To back up the few staff who have received training on postabortion care, the hospital needs to liaise with Ministry of Health to arrange training especially for registered midwives and clinical officers on postabortion care. This will improve the initial clinical assessment and examination of abortion patients with complications when they arrive to the gynaecological ward for treatment. The treatment protocol on first trimester incomplete abortion needs to be changed. Since the hospital already has a manual vacuum aspirator, ensuring its use on incomplete abortion patients in first trimester would reduce the average length of patient stay and the high treatment costs that both the hospital and the patients meet. The advantages of using a manual vacuum aspirator (MVA) versus the traditional dilatation and curettage (D&C) procedure have already been outlined. However, it must be reemphasized that it will promote the immediate provision of postabortion family planning services in the gynaecological ward if the hospital started offering these services. Regarding the high death toll resulting especially from severe haemorrhage and with the knowledge that safe blood in some occasions becomes difficult to secure in the hospital, expansion of the existing blood bank to cater for the high demand for safe blood is an avoidable necessity. This would help reduce even the countless deaths that happen when patients have to find themselves being referred for blood transfusion from Soroti hospital to other health facilities. Sound information is a prerequisite for health action. Without data on the dimensions, impact and significance of a health problem it is neither possible to create an advocacy case nor to establish strong programmes for addressing it. Soroti hospital administration should take a leading role in computerizing its records department and train the responsible staff in basic computer packages. The financial allocation by Ministry of Health to Regional Referral Hospitals also needs to be revisited. A hospital with a very high patient load cannot operate without drugs for three weeks each month. The Government of Uganda ought to know that a healthy population is a potential resource for the country’s development. Last but not least, the call to make abortion legal may not yield much at this stage. Many respondents had a negative opinion on termination of a pregnancy that resulted from contraception failure. As outlined in the 1994 International Conference on Population and Development (ICPD) in Cairo, Egypt and at the follow-up conference in New York, USA; the immediate priority in Uganda still remains making abortion services available to the full extent permitted by the law. The government and people of Uganda need to extend the spirit that made them score good results in their battle against HIV/AIDS to yet another campaign against unintended pregnancies and unsafe abortion