Maternal outcome of pregnancy in Mozambique with special reference to abortion-related morbidity and mortality

Abstract

In the capital city of one of the least developed countries, and using a hospital-based approach, the general aim was to characterise women who have undergone illegally and legally induced abortions, and to show the magnitude of both maternal mortality and abortion-related severe morbidity in adolescents and non-adolescents, in order to call the attention of decision-makers and health planners to this hazardous reality.

Methods: In the Department of Gynaecology and Obstetrics of the Hospital Central do Maputo, 103 women undergoing induced legal abortion (LA), 103 women with confirmed, recent illegal abortion (IA), and 100 antenatal clinic (AC) attendees were compared, in order to find characteristic features regarding level of education, habitation, household, employment and religious belief. Reproductive characteristics were also compared. Prevalence of sexually transmitted diseases (STDs) among LA and IA women was also studied. Outcome measures comprised treatment cost ill hospital and individual cost for the woman and post-abortion health consequences. During the five-year period 1989-1993, all maternal deaths among deaths of women 10-45 years were analysed. Information was recovered from medical records, antenatal cards and autopsy records, if available. All the admission books during 1990-1999 from the gynaecology emergency ward were reviewed in order to retrieve all data on women who had sought care for incomplete abortion. For those cases of severe morbidity that were submitted to surgery tile registration books of the operating theatre were reviewed. Individual records of the deceased women were also examined.

Results: Women with IA, in relation to women with LA, differed significantly in the following respects: they were younger. more often single, had lower income and education and belonged to the lower social stratum. They were less often Catholics. More often, their first sexual intercourse and their first pregnancy occurred below 20 years of age and they ]lad less knowledge of contraceptives. AC women were found to be similar to LA women in several respects but the pattern was not consistent throughout. Three maternal deaths occurred, all in the IA group. The most frequent illegal abortionist was a health worker. The hospital cost was significantly higher for IA than for LA women - the opposite was found regarding individual costs. The prevalence of syphilis, gonorrhoea and chlamydial infection was high and similar in both IA and LA groups. The MMR among adolescents was higher than among non-adolescents and the most prevalent causes of death in adolescents were malaria (27%) and pregnancy-induced hypertension/eclampsia (21%). Out of 148 women with severe complications of induced abortion 38 died shortly after admission and 110 women were submitted to surgical intervention, due to peritonitis. Out of these 110 as many as 55 (50%) had associated uterine perforation. Twenty-three (21%) died after surgery. Haemorrhage and sepsis were the most common complications.

Conclusion: IA women in Maputo belong to a poor segment of the population and safe abortion is more expensive for the individual woman than an unsafe, illegal one. They are at a disadvantage regarding early, unprotected sexual intercourse with first pregnancy at a young age and with almost no experience of safe abortion. The tragic complications of unsafe abortion, particularly the adolescent maternal deaths, should be addressed. Access to contraceptives and to safe legal abortion, should be improved. Urgent interventions are needed to reduce the high prevalence of STDs and consequently their adverse consequences.