Unsafe abortion in Tanzania : an empathetic approach to improve post-abortion quality of care

Abstract

Background: Unsafe abortion constitutes a major public health problem throughout the world, leading to high levels of maternal morbidity and mortality. To address the problem of unsafe abortion, there is need of reliable data that document the magnitude of the problem and describe the population at risk. In addition there is a need of well-documented and evaluated intervention studies that focus on reducing the high maternal mortality, which is associated with unsafe abortion.

Objective: i) to describe the magnitude of the problem of hospitalised unsafe abortion, ii) to characterise and compare socio-economic characteristics among women having unsafe abortion, spontaneous abortions and women receiving antenatal care, iii) to develop a method of providing post abortion family planning that is designed to the interests and needs of women having unsafe abortion, and iv) to evaluate if it is possible to make women having unsafe abortion use a contraceptive method, which prevents them from repeated, unwanted pregnancy.

Study population: Sub-study one. The study population comprised 1125 women with incomplete abortion and 307 women receiving antenatal care, who attended Dodoma Regional Hospital, Dodoma, Muhimbili National Hospital and Temeke Municipal Hospital, Dar es Salaam, during the period Dec 1996- May 1997. Sub-study two: The study population comprised 1357 women with incomplete abortion, who attended Temeke Municipal Hospital, Dar es Salaam during the period Jan 2001 -July 2002.

Method: Sub-study one. Women with incomplete abortion were interviewed with an empathetic approach and were classified as having either admitted unsafe abortion or spontaneous abortion. A reference group of pregnant women receiving antenatal care were recruited consecutively. The three groups were compared by use of a case-referent design. The variables studied comprise data on age, civil status, education, occupation, dwelling characteristics, religion, and reproductive characteristics. Sub-study two: Women having unsafe abortion were identified by using the empathetic approach and thereafter provided with ward-based contraceptive counselling and service. Follow-up information was retrieved after 1-6 months and the women's contraceptive compliance was assessed.

Results: Sub-study one. 60 % of women with incomplete abortion admitted unsafe abortion. Women having unsafe abortion were younger, more often single and more often students than women attending antenatal care. Sub-study two: 90% of the approached women with admitted unsafe abortion accepted contraceptives; follow-up information was retrieved among 315 (65%) women, of whom 204 returned spontaneously, whereas 111 were visited at home. In all, 271 (86%) stated use of contraception 1-6 months after discharge, 79% stated use of hormonal contraception, 7% stated reliance on condom only, and 14% stated no contraceptive use. Among the 44 women, who stated no contraceptive use, 45% intended to become pregnant again, 20% had no sexual partner, 18% feared side effects, whereas 16% stated other reasons.

Conclusion: By use of an empathetic approach it is possible to identify women having unsafe abortion and thus define the population at risk. In addition, the study has proven, that it is possible, by high quality contraceptive counselling combined with an empathetic approach, to address the unmet contraceptive need among women having unsafe abortion.