High severity of abortion complications in fragile and conflict-affected settings: a cross-sectional study in two referral hospitals in sub-Saharan Africa (AMoCo study)

Background: Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR). Methods: We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records’ reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity. Results: We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%). Conclusion: Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings. This article focuses on one component of the AMoCo study: a quantitative cross-sectional study conducted using a prospective medical record review among women with pregnancy losses before fetal viability. Additional file 1 describes all components of the mixed-method AMoCo study. This study is registered with ClinicalTrials.gov, {“type”:”clinical-trial”,”attrs”:{“text”:”NCT04331847″,”term_id”:”NCT04331847″}}NCT04331847. For this study, we used a methodology similar to the WHO Multi-Country Study on Abortion (WHO-MCS-A) [31] to generate comparable results to their study conducted in 210 facilities with Comprehensive Emergency Obstetric Care (CEmOC) capacity in 11 African countries [18]. We collected additional data to be able to also generate estimates using sub-Saharan African context-appropriate severity criteria. Results are reported according to the STROBE guidelines [32]. We selected two referral hospitals supported by Medecins Sans Frontieres (MSF, a non-governmental organization) in two different types of fragile and conflict-affected settings: an urban setting in CAR (Bangui); and a rural setting in northern Nigeria (Jigawa State). Each setting had to meet the following criteria: hospitals were in areas where the security of participants and researchers could be guaranteed; hospitals had wide catchment areas (≥ 500,000 inhabitants); provided post-abortion care to at least 500 women per year; conducted > 1000 deliveries per year; and were capable of providing all CEmOC signal functions. Signal functions are key medical interventions needed to provide emergency obstetric care including: the capacity to remove retained products; provide blood transfusion; and conduct abdominal surgery [31]. MSF supported the provision of free comprehensive SRH care in both facilities. CAR is a country of 5.4 million inhabitants, with 71% of the population living below the international poverty line in 2020 [33] and where 35% of women of reproductive age have not attended formal school [34]. In 2017, it had the fifth highest maternal mortality ratio in the world, with 829 maternal deaths per 100,000 live births [3]. Abortion complications were the primary cause of maternal deaths (25%) in a study conducted in six districts in 2010 [35]. A chronic civil war involving several non-state armed groups has ravaged CAR for decades, trapping the population in a cycle of indiscriminate violence; nearly 70% of the country remained under the control of armed groups in 2019 [36]. The country ranked sixth out of 178 states on the Fragile States Index in 2020 [37]. The study hospital, situated in an urban area of the capital Bangui, served a catchment population of approximately 505,000 people, including 160,000 internally displaced persons in 2017. The area of this hospital and its catchment population were regularly affected by armed attacks during the inclusion period of the participants in this study. In 2019, this hospital provided care to more than 10,400 women seeking childbirth care and almost 2500 women seeking post-abortion care [38]. In CAR, safe induced abortion is authorized by law before 8 weeks of pregnancy if the woman’s health is in danger, in case of fetal impairment, incest, rape, or when a minor is in a “serious distress state”, and if it is provided by a medical doctor [39]. Nigeria had an estimated population of 206 million inhabitants in 2020 [40] and had the fourth global highest maternal mortality ratio in 2017 at 917 per 100,000 live births [3]. The country ranked twelfth of 178 states on the Fragile States Index in 2021 [41]. The Nigerian study hospital is situated in Jigawa State, a poor rural state in northwest Nigeria where 87% of the population live below the poverty line [42]. In this State, the maternal mortality ratio is estimated to be 1012 per 100,000 live births [43] and 75% of women of reproductive age never attended formal school [44]. During the period of participants inclusion, the Jigawa State was in a fragile situation as defined by the World Bank [6]. Jigawa State has reported frequent floodings [45, 46], herders-farmers clashes, kidnappings, and influx of displaced people because of conflicts between different armed groups including Boko Haram, the Islamic State in West Africa Province and various communal militia in the neighboring States of Yobe, Katsina, and Borno [47]. The study hospital had a catchment population of about 665,000 inhabitants in 2020, but around 50% of patients came from outside the catchment area (including conflict-affected neighboring states like Yobe and Katsina) [48]. In 2019, it provided care to 9150 women seeking childbirth care and to around 500 women who sought post-abortion care [38]. In northern Nigeria, safe induced abortion is legal when the procedure aims to preserve the life of a pregnant woman, and when performed by qualified practitioners [39]. While both countries have recently developed national safe abortion care guidelines [49, 50], training for providers and access to safe abortion care remain very limited. All women presenting to the study hospitals with any signs or symptoms of pregnancy-loss-related complications or deaths at discharge were eligible for inclusion. Pregnancy loss included spontaneous/induced abortion, ectopic pregnancy, or molar pregnancy before fetal viability (28 weeks of gestation). Women with threatened abortion (defined as vaginal bleeding with a closed cervix) were excluded. In accordance with the Council for International Organizations of Medical Sciences guidelines [51], an informed consent opt-out procedure was set up in each facility, and women who opted out were excluded. This study reports on the results of the medical record review among women with complications from either a spontaneous or induced abortion. Additional file 2 describes the Prospective Medical Record Review methodology in detail. The sample size was computed to estimate with precision the proportion of severe maternal outcome, which includes near-miss cases and deaths, among all women presenting with abortion complications in each study hospital. The minimum target sample size was 430 women with abortion complications. The included participants presented between February 2020 and July 2021 at the Nigerian hospital (with an interruption between April and July 2020 due to COVID-19) and between November 2019 and January 2020 at the CAR hospital. Using a list of standard key words about symptoms and diagnoses (for example “vaginal bleeding”, “abortion”, “sepsis”), trained study clinicians screened the triage, gynecology/obstetric, and intensive care wards’ registers daily to identify potentially eligible women. They reviewed medical records of these women with a standardized eligibility form and included them in the study the same day as their presentation if they were eligible and did not opt out. Thereafter, they extracted data from their MSF standardized PAC medical records daily till their admission ended, consulting the clinician in charge of their medical management. They recorded sociodemographic data, reproductive history, obstetric characteristics, clinical signs and symptoms, laboratory markers, medical management, clinical outcomes, and status at discharge. We also collected aggregate data on the weekly number of live births and pregnancy-related admissions from each hospital’s health information system to calculate the magnitude endpoints. Both hospitals use the same MSF maternal health information system including standardized PAC medical records, variable definitions, and monitoring systems. Quality assurance procedures were implemented to ensure the collection of high-quality data. In summary, all standardized data collection tools, and procedures were piloted and revised. Standardized detailed definitions of each severity criteria and types of complications were used to collect consistent and comparable data in both study sites (see definitions in Table 1, Additional file 3 and Table 4). The full details of our quality assurance process can be found in Additional file 2. The study staff received an initial 2-weeks training and refresher trainings when participant inclusion was stopped and restarted due to COVID-19. Tracking of eligible women was done twice a day by the two different study clinicians to ensure that no eligible women were missed. They also checked all collected data against the corresponding medical record on site twice. The physicians on the central study team (CF, EP, HC, OO) performed additional monitoring and supervision remotely and on site especially on the data needed to diagnose types of complications and assign severity classifications to ensure comparability across study sites. Any identified data inconsistencies were corrected. WHO-MCS-A severity classification of abortion complications [18] and adaptations to reflect the Sub-Saharan Africa healthcare context • abnormal physical examination findings on initial assessment (vital signs, appearance, mental status, abdominal examination, gynaecological examination) • severe bleeding, • abdominal syndrome, • and/or uterine infection • severe systemic infection, • uterine perforation • and/or severe haemorrhage Same with these adaptations: • severe haemorrhage: o adding a threshold for systolic blood pressure < 100 mmHg o adding bleeding + Hb < 4 g/dL to the definition • adding the following conditions: o generalized peritonitis o other intra-abdominal perforation • deaths at discharge • + near- miss cases defined by the WHO near-miss criteria [52] for organ dysfunction of either one or more of the following: cardiovascular, respiratory, renal, hepatic, neurological, uterine or coagulation/hematologic dysfunction (with transfusion of ≥5 units of blood) a Detailed definitions of each condition in both original and adapted WHO-MCS-A classifications are in Additional file 3 Main reported types of abortion complications and underlying conditions, their near-miss risk and CFR aSevere bleeding/hemorrhage includes severe vaginal bleeding (heavy bright red vaginal bleeding AND/OR pads/towels/clothing blood-soaked within 5 min AND/OR pallor with bleeding) and severe hemorrhage (blood loss > 1 L OR blood loss with  systolic blood pressure < 100 mmHg or requiring 1 unit of blood transfusion or with  hemoglobin < 4 g/dL) bInfection includes uterine infections (fever/chills AND/OR foul-smelling vaginal discharge), generalized peritonitis (temperature > 38.5 °C AND abdominal guarding, rebound +/− ileus) and severe systemic infections (temperature > 38 °C AND suspected or confirmed infection AND at least one of the following: 1) new/worsened altered mentation. 2) respiratory rate ≥ 22/Min. 3) rystolic blood pressure ≤100 mmHg) cTrauma/perforation includes evidence of cervix/vaginal mechanical injury at clinical examination, uterine perforation or other intra-abdominal perforation confirmed at laparotomy dSevere bleeding/hemorrhage reported before presentation to the hospital and/or diagnosed during admission until discharge eThe threshold for anemia and severe anemia is defined according to WHO recommendations [59] fThe near-miss risk is the number of near-miss cases among the total number of cases of each type of abortion complications or underlying conditions gCFR: the Case Fatality Risk is the number of deaths among the total number of cases of each type of abortion complications or underlying conditions hMissing values < 2% i 4% < missing values < 10% The magnitude of abortion-related complications was estimated using two indicators: the number of abortion-related admissions per 100 pregnancy-related admissions and per 1000 live births. Pregnancy- or abortion-related admissions were defined as all women who presented to the hospital for a pregnancy- or abortion-related reason respectively and for whom a medical record was opened. Based on clinical, laboratory and management-based indicators identified at presentation or during hospitalization, the severity of abortion-related complications was classified into four mutually exclusive categories of progressively higher severity in line with the WHO-MCS-A classification [18]: mild complications, moderate complications, potentially life-threatening complications (PLTCs), and severe maternal outcomes (SMO). Women were classified into the highest level of severity for which they met the criteria. SMOs include near-miss cases and deaths (based on woman’s status at discharge). An abortion-related near-miss case is a woman who nearly died but survived a life-threatening complication that occurred during a spontaneous or induced abortion or within 42 days of the end of the pregnancy [52, 53]. It was defined using the 25 WHO near-miss criteria [52]. PLTCs and SMOs constituted “severe complications”. For the primary estimates generated from our analysis, some adaptations were made to the WHO-MCS-A classifications to calculate estimates reflecting the Sub-Saharan Africa healthcare context. The WHO-MCS-A classification with these adaptations is called the “Sub-Saharan Africa (SSA) adapted WHO-MCS-A classification” for the rest of the paper. To classify a woman in the SMO category, we used a cut-off of two or more units of blood transfused instead of five for the hematologic/coagulation dysfunction criteria as recommended by Tura et al. [54] and other African abortion studies [53, 55]. To classify a woman in the PLTC category, “any bleeding and haemoglobin <4g/dL”, “generalized peritonitis” and “other intra-abdominal perforations” were added to the criteria of PLTC as recommended by other abortion studies [53, 55, 56]. In addition, we noted that no systolic blood pressure (SBP) threshold was indicated in WHO-MCS-A to classify a woman as having severe haemorrhage in the PLTC category. Therefore, we defined hypotension as a SBP < 100 mmHg as per Green et al. [57]. Table ​Table11 summarizes the definitions of each of the four severity categories of the original WHO-MCS-A [18] and the adaptations made in this study. We calculated the facility-based abortion-related mortality ratio, near-miss ratio, and mortality index for each facility as defined in the WHO near-miss approach guidelines [58]. Sensitivity analysis was conducted to compare our frequency distributions across the four severity categories, the facility-based near-miss ratio and mortality index with the WHO-MCS-A’s results using the original WHO-MCS-A criteria [18]. For each type/underlying condition of abortion complication reported (hemorrhage, infection, traumatism/perforation, anemia), the near-miss risk and the case fatality risk (CFR) were computed. The near-miss risk is the number of near-miss cases per 100 cases of each abortion complication type/underlying condition. And the CFR is the number of deaths per 100 cases of each complication type/underlying condition. Gestational age at presentation was categorized as first trimester (fewer than 13 weeks), second trimester (13 weeks or more) and was estimated from weeks of gestation using the ultra-sound assessment as the reference assessment method. For those missing this information, we used the last menstrual period date or, if missing, the uterine size assessed by the provider, or if missing, the provider’s estimation of gestational age. Marital status was categorized as currently married or in union (married/living with a partner) or not (single/separated/divorced/widowed). We performed descriptive analysis using Stata 16.0 software (College Station, Texas, USA). Sociodemographic, reproductive, obstetrics characteristics of the sample as well as the percentage of women in each severity category, the mortality, near-miss and magnitude indicators were described using summary statistics. We calculated 95% confidence interval (95% CI) using exact methods. In each study hospital, a local steering committee involving members from the Ministries of Health and Social Affairs, local researchers, local administrative and religious leaders as well as women’s and civil society organizations participated in the study conduct oversee, interpretation of the results, and dissemination of the findings.