Date Published: February 16, 2018
Publisher: Public Library of Science
Author(s): Tadele Melese, Dereje Habte, Billy M. Tsima, Keitshokile Dintle Mogobe, Mercy N. Nassali, Ganesh Dangal.
Post abortion complications are the third leading cause of maternal death after hemorrhage and hypertension in Botswana where abortion is not legalized. This study aimed at assessing the management of post abortion complications in Botswana.
A retrospective study was conducted at four hospitals in Botswana in 2014. Socio-demographic, patient management and outcomes data were extracted from patients’ medical records. Descriptive statistics and chi-square test were used to analyze and present the data.
A total of 619 patients’ medical records were reviewed. The duration of hospital stay prior to uterine evacuation ranged from less than an hour to 480 hours. All the patients received either prophylactic or therapeutic antibiotics. Use of parenteral antibiotics was significantly associated with severity of abortion, second trimester abortion, use of blood products and the interval between management’s decision and uterine evacuation. Uterine evacuation for retained products of conception was achieved by metallic curettage among 516 (83.4%) patients and by vacuum aspiration in 18 (2.9%). At all the study sites, Misoprostol or Oxytocin were used concurrently with surgical evacuation of the uterus. None use of analgesics or anesthetics in the four hospitals ranged between 12.4% to 28.8%.
There is evidence of delayed patient care and prolonged hospital stay. Metallic curette was the primary method used for uterine evacuation across all the facilities. Pain management and antibiotics use was not standardized. A protocol has to be developed with the aim of standardizing post abortion care.
Globally an estimated 42 million abortions occur annually of which 20 million are unsafe. Complications of unsafe abortion lead to 70,000 maternal deaths and 5 million permanent or temporary maternal disabilities per year. Higher morbidity and mortality of women has been observed in the regions with restrictive abortion laws. It is also noted that both cases of spontaneous and induced abortion present to health facilities as cases of spontaneous miscarriage for post abortion care [2, 3]. Traditionally, management of spontaneous abortion involved surgical evacuation of the uterus using dilatation and curettage for prevention of infection due to retained products of conception. Progressively the use of manual or electrical vacuum suction has been widely recommended to replace dilatation and curettage for gestational age less than 13 weeks. This is because vacuum aspiration has fewer complications compared to metallic curettage and can be performed by mid-level health workers [5–7]. The World health organization (WHO) recommends the use of vacuum aspiration as the standard of care in the management of abortion of gestational age below 14weeks.
The management of post-abortion complications among 619 patients who presented to the study sites was reviewed. The details of the background characteristics of the patients are described elsewhere . At the time of inpatient care, 315 (50.9%) of the patients were reported to be HIV negative, 142 (22.9%) were HIV positive and 162 (26.2%) had an unknown HIV status.
All the patients had received either prophylactic or therapeutic dose of antibiotics. There was preferential use of metallic curettage for uterine evacuation compared to vacuum aspiration across all the four hospitals. A significant proportion of patients were admitted as referrals. Similarly, significant number of patients had delayed intervention. This may have had a negative impact on patient outcomes such as the high case fatality rate and the protracted hospital stay of more than 24 hours observed in 36.7% of patients. The patient care in terms of uterine evacuation, pain management, antibiotic use and admission to intervention interval was neither standardized nor uniform. This highlights a critical need to develop guidelines and protocols to ensure appropriate patient management across hospitals in Botswana.
This study being retrospective in nature and due to incompleteness of information, limited our ability to analyze triage to admission time and decision of management to intervention time which could have had crucial impact on patient management outcomes. Our study did not assess the practice of manual or electrical vacuum aspiration by mid-level and junior health care providers. The type of antibiotics used in the management of post abortion complications and the place of procurement of self-induced abortion by the patient is not addressed in this study and these are areas for future investigations.
This study has revealed that there was a delay in initiation of critical emergency post abortion care such as uterine evacuation. When curettage is performed, there was a preference of metallic curette over vacuum aspiration. Pain management and use of antibiotics was not standardized. Standardizing patient management protocols in terms of uterine evacuation, antibiotics use and pain management is mandatory. The use of WHO recommended less invasive vacuum aspiration or medical means of uterine evacuation should be strengthened. Decentralization of post abortion care services is recommended in order to avoid delayed initiation of patient care. A prospective study with the objective of investigating the process of triage to admission and intervention is strongly recommended. Further investigation of health care providers’ experience towards use of manual or electrical vacuum aspiration in the management of post abortion complications is also recommended. It is important to strengthen incorporate post abortion care training into the curriculum of medical professionals in Botswana.