**Post Abortion Care Services in Nigeria**

### Echendu Dolly Adinma

*Department Of Community Medicine, Faculty Of Medicine, College Of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Nnewi, Anambra State, Nigeria* 

#### **1. Introduction**

124 From Preconception to Postpartum

evacuation. *Fertil Steril.* Vol. 91, No. 1, (Jan 2009), pp. 28-31, ISSN 0015-0282 Pridmore, BR; & Chambers, DG. (1999). Uterine perforation during abortion: a review of

Rasch V. (2011) Unsafe abortion and postabortion care – an overview. *Acta Obstet Gynecol* 

Rehan, N. (2011). Cost of treatment of unsafe abortion in public hospitals. *J Pak Med Assoc.*

Rosenfield, A. (1994). Abortion and women's reproductive health. *Int J Gynaecol Obstet.* Vol.

Salakos, N; Iavazzo, C; Bakalianou, K; Gregoriou, O; Poltoglou, G; Kalmantis, K; & Botsis, D.

Sedgh, G; Henshaw, SK; Singh, S; Ahman, E; & Shah, IH. (2007) Induced abortion: estimated

Shah, I; & Ahman, E. (2010). Unsafe abortion in 2008: global and regional levels and trends. *Reprod Health Matters.* Vol. 18, No. 36, (Nov 2010), pp.90-101, ISSN 0968-8080 Shannon, CS; Winikoff , B; Hausknecht, R; Schaff, E; Blumenthal, PD; Oyer, D; Sankey, H;

Shaw, A. (2011) 'They say Islam has a solution for everything, so why are there no

Srinil, S. (2011) Factors associated with severe complications in unsafe abortion. *J Med Assoc* 

Tang OS; Gemzell-Danielsson, K; & Ho, PC. (2007). Misoprostol: pharmacokinetic profiles,

Tang, OS; Schweer, H; Lee, SW; & Ho PC. (2009). Pharmacokinetics of repeated doses of misoprostol. *Hum Reprod.* Vol. 24, No. 8, (Aug 2009), pp.1862-9, ISSN 0268-1161 Tang, OS; Schweer,H; Seyberth, HW; Lee, SW; & Ho PC. (2002). Pharmacokinetics of

Warriner, I; Wang, D; Huong, N; Thapa, K; Tamang, A; Shah, I; Baird, DT; & Meirik, O.

Nepal. *Lancet.* Vol. 377, No. 9772, (Apr 2 2011), pp.1155-61, ISSN 0140-6736 Zhou, C; Wang, XL; Zhou, XD; Hesketh, T. (2011). Son preference and sex-selective abortion

effects on the uterus and side effects. *Int J Gynaecol & Obstet.* Vol. 99, No. Suppl 2,

different routes of misoprostol. *HumReprod.* Vol. 17, No. 2, (Feb 2002), pp.332-6,

(2011). Can midlevel health-care providers administer early medical abortion as safely and effectively as doctors? A randomised controlled equivalence trial in

in China: informing policy options. *Int J Public Health*. 2011 Jun 17. Epub ahead of

in Britain. *Bioethics*. 2011 Jun 7. Epub ahead of print. ISSN 0269-9702 Singh, S; Sedgh, G; Hussain, R (2010). Unintended pregnancy: worldwide levels, trend, and outcomes. *Stud Fam Plann*. Vol. 41, No. 4. (Dec 2010), pp.241-50, ISSN 0039-3665 Song, J. (2000). Use of misoprostol in obstetrics and gynecology. *Obstet & Gynecol Survey.* 

Vol. 55, No. 8, (Aug 200), pp.503-510, ISSN 0029-7828

(Dec 2007), pp.S160-7, ISSN 0020-7292

*Thai*. Vol. 94, No. 4, (Apr 2011), pp.408-14, ISSN 0125-2208

*Scand*. Vol. 90, No. 7, (Jul 2011), pp.692-700, ISSN 0001-6349

Vol. 61, No. 12, (Feb 2011), pp.169-72, ISSN 0030-9982

46, No. 2, (Aug 1994), pp.173-179, ISSN 0020-7292

Vol. 35, No. 2, (2008), pp.130-2, ISSN 0390-6663

ISSN 0140-6736

ISSN 0029-7844

ISSN 0268-1161

print. ISSN 1661-8556

(Aug 1999), pp.349-353, ISSN 0004-8666

pregnancy by single-dose 800 microg misoprostol compared with surgical

diagnosis, management and prevention. *Aust N Z J Obstet Gynaecol.* Vol. 39, No. 3,

(2008). Misoprostol use as a method of medical abortion. *Clin Exp Obstet Gynecol.* 

rates and trends world wide. *Lancet.* Vol. 370, No. 9595, (Oct 13 2007), pp.1338-45,

Wolff, J; & Goldberg, R.(2005). Multicenter trial of a simplified mifepristone medical abortion regimen. *Obstet Gynecol.* Vol. 105, No. 2, (Feb 2005), pp.345-351,

guidelines for this?' Ethical dilemmas associated with the births and deaths of infants with fatal abnormalities from a small sample of Pakistani Muslim couples Abortion, whether spontaneous or induced, may be associated with complications that constitute global public health challenge especially in developing countries. In many such countries, abortion is often both unauthorized and unsafe. Only the wealthy and more educated women have access to safe procedures, leaving the poor and often marginalized women to suffer disproportionately, on account of illegal, or restrictive abortion laws (Bankole et al., 2006; Faúndes & Barzelatto, 2006). In countries with restrictive abortion laws, due to the absence of legal abortion services, women attempt to end unwanted pregnancies through clandestine means. Such women terminate pregnancy by themselves, and sometimes in collaboration with quacks in unhygienic environments (Bankole et al., 2006). The techniques used in most cases are likely to cause morbidities such as genital track trauma, haemorrhage, and infection, or even outright maternal deaths (Ahiadeke, 2001; Rogo, 1993). To compound the problem, when most women in developing countries miscarry or suffer potentially life-threatening complications from unsafe abortion, they rarely have access to prompt treatment (Rogo, 1993). Whereas a woman's life time risk of dying from complications of pregnancy or childbirth in Europe is 1 in 600, it is outrageously high in Africa with figures as high as one in 7 in Ethiopia, for example, with more than half of those deaths attributable to unsafe abortion (WHO, 2001). The risk of death from unsafe abortion in developing countries is the highest in the world with a case fatality rate of 0.7 % for sub-Saharan Africa (WHO, 1998). with

Post abortion care (PAC) is a global approach towards solving the problem of maternal mortality and morbidity arising from abortion complications from both spontaneous and induced abortion. It consists of a series of medical and related interventions designed to manage the complications of abortion. Its overall aim is to reduce maternal morbidity and mortality from abortion and its complications, and to improve women's sexual and reproductive health and lives. A comprehensive post abortion care service has been identified to be useful in ameliorating the often adverse health consequences associated with unsafe abortion in regions with restrictive abortion laws.

Post Abortion Care Services in Nigeria 127

law in African countries are based on very restrictive 19th century European penal code permitting legal abortions only to save the life of the woman (Henshaw, 1990; Cooks et al., 1999). For example, in Nigeria, abortion law is restrictive and encoded in the portions of the Criminal and Penal codes related to miscarriage, culled from the "British Offence against the persons" Act of 1861 and annotated by S. S. Richardson in 1933, excerpts of which is as

This is applicable mainly in Southern Nigeria and includes Sections 228, 229, 230, 297 and

Any person who, with intent to procure miscarriage of a woman whether she is or is not with child, unlawfully administers to her or causes her to take any poison or other noxious thing, or uses any force of any kind, or uses any other means whatever, is guilty of a felony,

Any woman who, with intent to procure her own miscarriage, whether she is or is not with child, unlawfully administers to herself any poison or other noxious thing, or uses any force of any kind, or uses any other means whatever, or permits any such thing or means to be administered or used to her, is guilty of a felony, and is liable to imprisonment for seven

Any person who unlawfully supplies to or procures for any person any thing whatever, knowing that it is intended to be unlawfully used to procure the miscarriage of a woman, whether she is or is not with child, is guilty of a felony, and is liable to imprisonment for

A person is not criminally responsible for performing in good faith and with reasonable skill a surgical operation upon any person for his benefit, or upon an unborn child for the preservation of the mother's life, if the performance of the operation is reasonable, having

Any person who, when a woman is about to be delivered of a child, prevents the child from being born alive by any act or omission of such a nature that, if the child had been born alive and had then died, he would be deemed to have unlawfully killed the child, is guilty of a

regard to the patient's state at the time and to all the circustances of the case.

follows:

**3. Criminal code act** 

328 of the Criminal code.

and is liable to imprisonment for fourteen years.

**3.1 Section 228** 

**3.2 Section 229** 

**3.3 Section 230** 

three years.

**3.4 Section 297** 

**3.5 Section 328** 

felony, and is liable to imprisonment for life.

years.

This chapter reviews the magnitude of abortion problems together with the place of PAC in the combat of abortion related maternal morbidity and mortality.

### **2. Magnitude of abortion problem**

Abortion is one of the most important direct medical causes of maternal mortality, accounting for 12-40 % of overall global maternal deaths (WHO, 1994; Fatusi & Ijadunola, 2003). World Health Organization estimates that 46 million induced abortions occur annually the world over (WHO, 1998). To attest to the enormity of this global abortion problem, Henshaw et al., 1998, in a comprehensive review of data on abortion further deduced that one out of every four pregnancies the world over is voluntarily terminated. Conservative estimate from Henshaw et al review of induced abortion indicates that 20 million induced abortions are performed under unsafe circumstances, causing the death of over 80,000 women annually (Henshaw, 1990; Henshaw et al., 1998; Henshaw et al., 1999. This, however, has regional variations, with rates as low as 2 per 1000 occurring in developed countries and as high as 28 per 1000 taking place in developing countries where restrictive abortion laws abound in great proportions (Ahman & Shah, 2002). In Nigeria with restrictive abortion law for example, Centre for Reproductive Rights reported maternal mortality of 34,000 attributable to abortion in 2008 alone (Centre for Reproductive Rights, 2008)!

Unsafe abortion has human, social and economic costs. While the human cost is related to physical complications that lead to the death of the woman, or associated long term sequelae, the social cost is related to the long-term physical limitations such as infertility, or from moral, legal or cultural stigma that women who abort may suffer. The economic cost is related to the reduction of health resources that would have been used for the management of critical health problems being diverted towards the treatment of abortion complications especially in developing countries (Faúndes & Barzelatto, 2006).

Every year, more than 4.2 million African women undergo unsafe abortion with an estimated 38,000 of them dying from the experience, leaving countless others with severe morbidities (Henshaw, 1990). These numbers represent over 50 % of all women globally who die from abortion-related causes (WHO, 1998). Amongst those surviving the ordeal, several thousands experience various forms of short- and long-term morbidities. The morbidities include uterine perforation, chronic pelvic pain, and secondary infertility. Victims of unsafe abortion may in addition suffer stigma and isolation forced on them by their families and communities.

Considering the huge contribution of unsafe abortion to the very high maternal mortality in most countries, it is apparent that efforts to reduce maternal mortality and improve maternal health without addressing the issue of unsafe abortion will not succeed.

Only 40 % of the population in the world lives in countries where abortion laws are unrestrictive such that abortion is permissible at the woman's request. The remaining 60 % live in areas with abortion laws of varied restrictions, and most of these are in developing countries (Rahman et al., 1997; Cooks et al., 1999). With only a few exceptions, the abortion law in African countries are based on very restrictive 19th century European penal code permitting legal abortions only to save the life of the woman (Henshaw, 1990; Cooks et al., 1999). For example, in Nigeria, abortion law is restrictive and encoded in the portions of the Criminal and Penal codes related to miscarriage, culled from the "British Offence against the persons" Act of 1861 and annotated by S. S. Richardson in 1933, excerpts of which is as follows:
