Determinants & Outcome of Safe 2nd Trimester Medical Abortion at JUMC

1. By: 1. AhaduWorkneh (MD,Assistant Prof.Gyn/Obs)2. YibeltalSiraneh(PH,MPH/HSM, PhD Fellow)JUIH *TM-MA, JUMC-Trimester Medical Abortion at Jimma Univeristy Medical Center Determinants and Outcomeof Safe 2nd TM-MA, JUMC*

2. OOOutline • Background • Rationale of the study • Conceptual framework • Objective of the study • Methods and participants • Result and Discussion • Conclusion and Recommendation • Aknowledgment & References

3. Background • 2nd TM Abortion is termination of pregnancy during 13 to 28wks ofGA (WHO, 2010) • Worldwide, Mid trimester abortion constitutes 10-15% of all induced abortions and accounts for the majority of complications (M. Muyuni...et al,2014) • In Africa, the proportionof 2nd TMA arefew as compared to 1st TM • However to appropriately intervene with a view to reducing the morbidity and mortality, the determinants & outcomes in resource limitted setting should be known (M. Muyuni...et al,2014) • As researches showed, the prevalence of induced 2nd TMA was • 34% in Kenya, • 30% in India • 25% in South Africa • 11% in Ethiopia, • 10% in Nigeria, and • 8.6% in England and Wales, (Susheela Singh...et al,2008) • In Ethiopian case, • Amhara Region’sprevalenceof 2nd TMA was 19.2% (Amlaku M.....et al,2015/R.Hospitals) • Prevalence of 2nd TMA in Jimma town is 13.7% out of all abortions. (kristine Ivalu B....et al,2014)

4. Background .... • Ethiopia revised its abortion law with adding more exceptions in 2005: • Rape, Incest, • Fetal defect, or • When the woman’s life or physical or mental health is endangered • However, 58,000 women seek care for complications of abortion in 2008 • 41% had moderate or severe morbidity, such as signs of infection, that were likely related to an unsafe abortion. • 7% of all women had signs of a mechanical injury or a vaginally inserted foreign body • Abortion-related deaths accounted for more than 30% of maternal deaths, from w/c 11% was due to 2nd TMA (FMoHHSDPII, FMoH, 2006 report)

5. Rationale/Justification 1. The prevalence in Jimma town is 13.7%, its’ determinants & outcome unknown? 2. CAC guidline/training manual (FMoH) define, safe 2nd TM-MA, as it shouldn’t cause any complication • Butabortionperformed after 20wks of GA are most commonly performed by dilation and evacuation (D & E) procedures, due to this; • 2nd TMA carries a higher risk of morbidity and mortality as compared to first-TMA[developing countries] • More than 1/3 of all women with abortion complications were seeking care after induced 2nd TMA (WHO,2010, kristine Ivalu B...et al,2014,) • Hence, even if provisionally called SAFE, the outcome should be assessed whether end up with complication or not! 3. In fact, determinants of abortion (reasons why terminated and delayed?) was assessed elswhere but not specific to outcome of safe 2nd TM-MA • 2nd TMA, aninherently more riskyprocedure,reasons why women delayseeking an abortion until the 2nd TM? Should be also studied (Jane Harries...et al,2010)

6. Significance of the study • Will be used as a baseline information/No similar study done • To have evidence based intervention that benefit the community/Women • May bring point of discussion and protocol revision among faculties and administrative bodies of JUMC • Indentfying the outcome is important to reinforce the need & safety of the intervention (safe 2nd TM-MA) • Indentfying determinants to inform policy makers to develop factor specific interventions

8. Objective of the study General objective • To assess the outcome and determinants of safe 2nd TM-MA among clients admitted at Gyn Ward, JUSH/JUMC. Specific objectives • To assess the maternal outcome of safe 2nd TM-MA • To identify factors that affectoutcome of safe 2nd TM-MA

9. Methods and participants Study area and period • JUSH/JUMC, Obs/Gyn ward,particulary Gyn ward/CAC services, • It was conducted from March 01-August30/2016=6 months • It was estimated that180 women were admitted for safe 2nd TM-MAover a period of 6 monthsfrom previous year records • Average rate of adimission was 30 clients/month---1/day

11. Operational definition • Complete abortionwithout complication • Expulsion in a reasonable period of time (after starting regimen within 48-72 hrs, using the protocol of the hosppital) without anycomplication • Incomplete abortionwith Complication • Presence of complication (retained products of conception/ incomplete abortion, hemorrhage, anemia, cervical/uterine/abdominal injury, shock, infection, vaginal wall lacerations, unchanged cervical status, need of transfusion and death) and/or failure of expulsion without active surgical intervention • Safe abortion means the termination of pregnancy carried out by accredited health professional with the skills or training to perform the procedure safely, in a place that meet minimum medical standard, in this case at specialized teaching medical center. However, women are able to access abortion services in specific circumstances that will be determined based on the chief complain of woman and the physician considering the legal conditions. • Cervical status is measured by effacement, dilatation, consistency & its position to decide whether it is closed or open. • Status of anemia categorized according to the following cut off points. Such as severe anemia (Hgb<7g/dl), moderate anemia (Hgb:7-10g/dl), mild anemia(Hgb: 10.1-10.4 g/dl) and no anemia(Hgb >=10.5g/dl). • Short term complication/s are/is that complication/s may occur starting from the intervention till discharge from the hospital. • Perceived physician skill: when the service provider has both adequate working knowledge and skill to provide the expected services that measured by patient perspective. It was measured by using 5-point likert scale ranging from 1-no skill to 5-had excellent skill, and the mean score used to categorize as “have no skill” =scored below mean score of 3.42 and “have good skill”= scored the mean value of 3.42 and above. • Attitude towardsabortion was measured by using 5-pointlikertscale and categorized into two as they had positive attitude if scored the mean value or above, or negative attitude if scored below the mean score. • Satisfactionon overall waiting time indicates that level of satisfaction of the client about the time that spent in the registration room, at the waiting area, at admission process, to get the physcian, consultation time and time to start the regimen. Level of satisfaction with over all waiting time from entry to exit was measured by 5-point likert scales ranging from 1-strongly disatisfied to 5-strongly satisfied then dichotomized into two using the mean score (1.78) as a cut off point. • Overall satisfaction on the comprehensive abortion care given to clients measured by 5-point likert scales ranging from 1-strongly disatisfied to 5-strongly satisfied, then dichotomized into two using the mean score as a cut off point (scored below the mean-7.21-disatisfied and scored mean value and above-7.21-satisfied) • Waiting time is the overall time spent from the entry to hospital till starting the medication for abortion (self-report time spent in the registration room, at the waiting place,admission process and time to start the regimen) • Cx status is measured by effeciment, dilatation, consistency & its position • Client is considered as an anemic when Hgb value is less than 11 gm/dl (mild,moderate & severe ) • Drug trial and failuremeans when she try medical abortion at first TM,it failed but she considered as it was terminated, infact not and that lead her to come at 2nd TM.

12. Result and Discussion Socio-demographic characterstics • The RR was 98.1% (201/205). • The mean age=21.26 (SD+ 4.83) years • with a range of 15 to 38 years. • 85 (42.3%) of them were between the ages of 15-19 years. • Nearly half 86 (42.8%) were followers of Orthodox and Muslim with equal %. • Around half 103 (51.2) were of Oromo in ethnicity. • More than three fourths 170 (84.6%) were single in marital status, and 168 (83.6%) literate. • More than half 111 (55.2%) of them were student in their occupational status. • More than two thirds 139 (69.2%) were urban residents • Morethan three fourths 159 (79.1%) had a monthly own income of 0 to 22.22USD,ranging from 0to 133.33 USD. Annexed Tables-Abortion.pdf (Refer to Table 1)

13. Outcome of Safe 2nd TM-MA • Majority 100 (59.8%) were b/n 12-18wks of GA , and 3/4th of them were Gravida I • Hemoglobin (Hgb) level at admission reported that almost all of them were non-anemic. • During the procedure for 179 (89.1%) bleeding estimated as within the normal range/expected. • None of the women had pelvic infection at admission • >3/4th 154 (76.6%) of them had complete expulsion using medication only=Complete abortion without complication • For 62 (40.8%) women the total time taken to expel using the recommedned dose of medication was 72 hr or less. (Range=12 to 96hrs) • <3/4th had incomplete abortion with one or more complications that was needed active surgical inervention (dilatation and curatage) and MVA; • Due to failure of expulsion, and retained products of conception, and • Anemia (mild to Moderate) were some of the incomplete abortion with complication • However, no record of injuiry or perforation or laceration due to the procedure on; • cervix/uterus/bowel/bladder/vagina, • No shock, infection, delayed vaginal bleeding, • blood transfusion, fever, diarrhea, and • Death Annexed Tables-Abortion.pdf (See Table 3) • @Zambia,University Teaching Hospital • Outcomes included • Complete abortion without any complication=53.1% • retained products of conception and shock= 11%, • haemorrhage, uterine perforation, • pain, infection, lacerations, • delayed vaginal bleeding and death. • Some women hadone & more than one complication • 68(46.9%) had one • 47(32%) had two and • 22(15.2%) had three complications (M. Muyuni...et al,2014) Possible reason; -Our case=most are 12-18GA -but Zambian case= 18-28GA -medication type-misoprostol as a standard in Ethio-more act <<GA -Eligiblity---prior medical or obstetric complications

14. However, it is consistent with what reported from FMoH; • Our study revealed less number of women who had incomlete abortion 23.4% with one or more complication as compared to the national level report (26%). • As 2nd TM-MA is an effective and safe method for legally eligible women; • However, much should be done to reduce unfavorable outcome by minimizing; • The abortion interval, • Rate of evacuation of uterus • The incidence ofminor side effects, so that to improve patients' satisfaction (EFMoH report, 2010) Our study result is different than reproted from Singapore; • They reported high incidence of minor side-effects eg fever(80%), pain(53%) and diarrhea (13%)by misoprostol only regimen, and low incidence of major complications such as blood transfusion (0.9%) andre-admission (0.2%). • But major complication eg. Death (0.1%),Blood transfusion (0.9%) and re-admission (0.2%) were rare (Yong, a kale, r mary,2010) The outcome difference might be due to women’s socio-demographic characterstics d/f, retrospective (analyzed from 20 data) nature of the other study which excluded women above 24wks of GA and study setting itself.

15. There is similarity b/n reasons why delayed till 2nd TM? • More than 1/3rd 75(37.3%) of women reported as the only reason for delay was fear of stigma, whearas the most frequent was related with attitude, and not informed of service availablity and legal conditions. • Similar with reproted from Englad/Walles and elswhere (Daniel Grossman, et al, 2011; Singh S. 2006) • There is no single reason why women have abortions in the second trimester /late seeking; • Much of the delay occurs prior torequesting an abortion • Women’s concerns about what is involved during abortion (fear 6%) • Various aspects of women’s relationships with their partners and/or parents play a role • women’s decision-making about whether to have an abortion (for 16% sexual partner) • After requesting an abortion, • Delays are partly service related (e.G. Waiting for appointments) • 93 and 48 women got the sevice after waiting for 1 wk and 2 wks or more of app. Time. • This is totally incompatable with WHO guidelines in which a woman who is eligible for pregnancy termination should obtain the service within three working days.(Temporary reason from observation-JUMC transition time) • Partly ‘woman related’ (e.g. missing or cancellingappointments) (Roger Ingham....et al,2012)

16. Predictors of Outcome of Safe 2nd TM-MA • Fromthe final model, Identified predictor variables were; • Contraceptive use, • Previous experience of abortion, • Gestational age, parity, cervical status, • Over all waiting time, and hemoglobin (Hgb) value • The likelihood of having complete abortion without any complication was 6 times higher among women who had previous experience of abortion as compared with counterparts [AOR= 6.001, 95% CI= (3.766, 8.885)]. • The likelihood of havingcomplete abortion without any complication decreased as gestational age increased. • About 9.8% of women whose gestational age was between 24.1-28weeks were [AOR=0.902, 95% CI= (0.074, 0.986)] less likely to had complete abortion without any complication as compared to those whose gestational age was between 12-18weeks. • Multiparawomen were 2.4 times [AOR=2.384, 95% CI= (1.040, 3.693)] more likely to had complete abortion without any complication as compared to nulliparous. • Similarly, women with open cervical status before taking recommended medication were 8 times [AOR=8.001, 95% CI= (5.715, 10.015)] more likely to had complete abortion without any complication as compared to women who had closed cervix

17. Predictors... • The odds of increased overall waiting time will decreasethe probability of having complete abortion without any complication. • About 46.9% of women who waited for more than two weeks to get abortion services [AOR=0. 531, 95% CI= (0.504, 0.963)] wereless likely tohad complete abortion without any complication as compared to those waited for one week. • About 92.9% of women with moderate anemia (Hgb:7-10g/dl) were [AOR=0.071, 95% CI= (0.004, 0.163)] less likely to have complete abortion without any complication as compared to those with no anemia. • Research in Zambia showed, the determinants of the 2nd TM-MA cases at the University Teaching Hospital were • Personal factors including Gyn/Obs factors (parity,GA,previous experiance) (M. Muyuni...et al,2014) • In Burkina Faso , Three key factors were significantly associated withinduced 2nd TMabortion • UnwantedPregnancy [OR] 10.45, 95%; [CI] 3.59–30.41) • Living in a household headed byparents (OR 6.83, 95% CI 2.42–19.24); • Divorced or widowed (OR 3.47, 95% CI 1.08–11.10) • Being married was protective against induced abortion, with women who reported being married having 83% lower chance of having an induced abortion, even when the pregnancy was unwanted (patrick Gc...et al,2014) Factors at Singapore; • There was no significant difference in treatment outcomes when taking maternalcharacteristics into consideration (parity, race, marital status, previous deliveries) • The younger agegroup (<35years old) who were at an earlier gestation age (12 to 16 weeks) are more likely to need evacuation of uterus tocomplete the termination (Yong, a kale, r mary,2010) • InJimma town(including the JUSH), determinants of abortions (not specific for 2nd TMA) • Socio-economic factors (marital status, religion , income, stigma) • Personal circumstances (indecision, lately detecting apregnancy, drug trial and failure, previous experiences, contraceptive history) • Health service related barriers (quality, non-client centered service) (Jane Harries...et al,2010/)

18. Bivariate and Multivariable LR

19. Limitations • The possible limitation of this study was; • The clinical part of data abstracted from the secondary data or patient’s chart. • This finding may be biased by the physician’s knowledge and skill who followed and did the procedures as well as documenting reliable information on the chart. • Some of the items were perception related and self-reported. • Social desirablity bias and interviewer bias might be also an other potential biases for such study condcuted on sensetive issues(abortion). • This finding may not be generalized to the target population because of non-probablity sampling technique used at a single facility.

20. Conclusion and Recommendation • This finding impliedthat proportion of complete abortion without any complication over-weigh incomplete abortions with one or more complication through induced safe second trimester medical abortion method. • In conclusion, more than three fourth of women had complete abortion without any complication while the remaining one fourth had incomplete abortion with one or more complication. • The outcome is strongly determined by gestational age, cervical status, previous experience of abortion, parity, moderate anemia and overall waiting time. • Induced second trimester medical abortion is already known as an effective and safe method. However, much should be done to reduce proportion of incomplete abortions by minimizing overall waiting time through intervening at low gestational age. • Therefore, it is recommended that safe second trimester medical abortion services should be provided [under a certain legal circumstances] so as to reduce maternal morbidity and mortality. • Women who are eligible for pregnancy termination should have the necessary information to seek abortion care as early in pregnancy as possible. • Health professionals should inform women as comprehensive abortion services are free of charges and to reduce stigma since those are the major reason for delay. • We afraid about the high report of RAPE (79%) which may mislead researchers, that may be due to the abortion law exceptionsof legal implication.

21. Acknowledgement • To CIHRT for providing guidance/support and fund • To JUSH-Medical Record Mg’t office • To Residents, Interns, Data collectors, study participants • To the site coordinator of CIHRT project-Mr.Bisrat

22. References • M. Muyuni, B. Vwalika, Y. Ahmed, The Determinants and Outcomes of Second Trimester Abortion at the University Teaching Hospital, Medical Journal of Zambia, Vol. 41, No. 1 (2014) • World Health Organization. Trends in Maternal Mortality: 1990 to 2010 WHO, UNICEF, UNFPA and the World Bank Estimates. Geneva: WHO; 2012. • Yong, A Kale, R Mary. A retrospective study of the outcomes of second trimester pregnancy termination using vaginal misoprostol. The Internet Journal of Gynecology and Obstetrics. 2007 Volume 9 Number 2 • Shah I, Ahman E. Unsafe abortion: global and regional incidence, trends, consequences, and challenges. J ObstetGynaecol Can. 2009;31 (12):1149–1158. • Marcia de Toledo Blake, Jefferson Drezett, Gilzane Santos Machi, et al, Factors associated to late-term abortion after rape, literature review,reprodclim. 2 0 1 4;2 9(2):60–65 • ZebaSathar, Susheela Singh, Gul Rashida, Zakir Shah, and RehanNiazi, Induced Abortions and Unintended Pregnancies in Pakistan, PMC,Stud Fam Plann. 2014 Dec; 45(4): 471–491. • Rasch V. safe abortion and postabortion care – an overview. ActaObstetGynecol Scand. 2011;90(7):692–700.  • Patrick GC Ilboudo, Serge MA Somda, Johanne Sundby, Key determinants of induced abortion in women seeking postabortion care in hospital facilities in Ouagadougou, Burkina Faso, International Journal of Women’s Health 2014:6 565–572 • Ethiopian Federal Ministry of health,report, 2006. http://www.who.int/pmnch/knowledge/publications/ethiopia_country_report.pdf • Ethiopia Ministry of Health, Health Sector Development Program IV in Line with GTP, 2010/11–2014/15, Addis Ababa, Ethiopia: Federal Democratic Republic of Ethiopia, 2010, and Ethiopian Abortion law-declaration-2005-Article 551. • Gezahegn , Induced Abortion and Associated Factors in Health Facilities of Guraghe Zone, Southern Ethiopia, journal of pregnancy, Volume 2014, Article ID 295732,8 page • Roger Ingham, Ellie Lee, Steve Clements and Nicole Stone, Second-trimester abortions in England and Wales, Centre for Sexual Health Research,University of Southampton,2012. www.psychology.soton.ac.uk/cshr • Amlaku Mulat.et al,2014, Induced Second Trimester Abortion and Associated Factors in Amhara Region Referral Hospitals, Journal of Pregnancy, Volume 2014 (2014), p8. • Kristine IvaluBonnen, DerejeNegussieTuijje and VibekeRasch, Determinants of first and second trimester induced abortion - results from a cross-sectional study taken place 7 years after abortion law revisions in Ethiopia,Bonnen et al. BMC Pregnancy and Childbirth (2014) 14:416 • Jane Harries, Phyllis Orner, Mosotho Gabriel and Ellen Mitchell, Delays in seeking an abortion until the second trimester: a qualitative study in South Africa, BMC, Reproductive Health 2010, 4:7 doi:10.1186/1742-4755-4-7 • Grimes DA, Benson J, Singh S, et al. safe abortion: the preventable pandemic. Lancet.2006; 368(9550):1908–1919.  • Hord C, Wolf M. Breaking the cycle of unsafe abortion in Africa. Afr J Reprod Health. 2004; 8 (1):29–36. • Daniel Grossman, Deborah Constant et al.: Surgical and medical second trimester abortion in South Africa: A cross-sectional study. BMC Health Services Research, 2011:224. • Singh S. Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries. Lancet.2006; 368 (9550):1887–1892.  • Abiodun OM, Balogun OR, Adeleke NA, Farinloye EO. Complications of unsafe abortion in South West Nigeria: a review of 96 cases. Afr J Med Med Sci. 2013; 42 (1):111–115.  • Berer M. Hospital admission for complications of unsafe abortion. Lancet. 2006; 368 (9550):1848–1849.

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