Unsafe Abortions in Adolescents

Facts on unsafe abortions in India

• Despite abortions being legalised in India 4 million women per year still resort to illegal abortions.
• Unsafe abortions are more common in unmarried girls.
• 50% of all maternal deaths in 15-19 year age group are due to illegal abortions.
• Complications due to unsafe abortions are medical and psychological.

The Nature and Scope of Unsafe Abortions

In India, though abortion has been legalized since 1971, illegal and unsafe abortions are very common due to various reasons.

Legal abortion : implies termination of pregnancy by trained provider in Government approved health facility for the purpose and fulfilling the conditions mentioned in the Medical Termination Act.

Illegal abortion : implies termination of pregnancy by trained provider violating the Medical Termination of Pregnancy Act.

Unsafe abortion : implies interference of pregnancy by persons without the necessary knowledge and skills, or in conditions that are not conducive to good health. It can be within or outside of the law.

Apart from the women who die due to post-abortion complications, there are many more who survive but have to live with chronic health problems, and in many cases infertility.

Factors contributing to Unsafe Abortions in Adolescents

• Delay in seeking abortion is the most important factor and the commonest cause of complications and death among adolescents. Delay is again due to ignorance (Not aware that pregnancy has occurred) or hoping to hide pregnancy till it becomes too late.
• The judgmental and unwelcoming attitudes of health providers can also lead to delay in reaching them.
• It is commoner among adolescents to go to untrained and unskilled providers especially when they are unmarried or the pregnancy is unintended and adolescent wants to get rid of it clandestinely (without informing the in-laws). The younger they are, it is more likely that they will be forced to opt for a potentially unsafe abortion conducted in an unhygienic condition by unskilled provider.
• Use of dangerous methods are also common in adolescents especially unmarried girls who are advised by mothers, untrained birth attendants, quacks, to insert foreign bodies into the cervix unhygienically or ingest certain potions or drugs.
• There is general lack of awareness among adolescents about the medical termination of pregnancy that can be availed at registered health facilities. These latter are however, inaccessible because of the family’s need for secrecy and confidentiality and bowing to societal and community demands.
• At present, health facilities do not offer user-friendly abortion services and some are not themselves aware of the rights of clients to these. Most clients feel that privacy and confidentiality is difficult to be maintained in public system.
• Even after a spontaneous abortion, an adolescent may have post abortion complications, if the abortion is not complete or some infection has set in due to retained products of conception and unhygienic practices of perineal region.

Consequences and consequences of unsafe Abortion

Complications due to unsafe abortions are high for all women; the adolescent group is especially at risk. Within this group, those who are very young, who are primigravida and the very poor are even worse off.

• Medical

Moor short term complication include cervical or vaginal lacerations, pelvic infection or abscess, sepsis, hemorrhage, perforation of uterus or bowel and septicaemia. Major emergency surgical interventions are often required and these are either not available or not accessible to the disadvantaged sections of society. Thus, in many cases, the unfortunate adolescents who are forced to resort to unsafe abortions, end up dying at a very young age or live with severely damaged reproductive tracts.

• Psychological

Within the confines of an unforgiving and rigid society, there is no psychological support for the adolescent recently traumatized by an unsafe abortion. In fact, even health providers do not see the need for this kind of a support. The girl is left alone in her misery, confusion and ignorance and guilt can set in compelling her to resort to risky behaviour and even suicide.

• Socio-economic

Girls who survive unsafe abortions face a range of social problems, from disapproval, rejection, even ostracism, from their families and communities. They can be thrown out by their families and forced into prostitution. Their options become very limited.

The family faces grave economic consequences of unsafe abortion and is at times, reduced to bankruptcy and ruin.

Diagnosis and Management of Unsafe Abortions

The diagnosis of unsafe abortion or its complications should not differ between adolescents and adult women and history of missed menstrual period(s) followed by an attempt to terminate the pregnancy should be sought. The girl is usually brought to the health facility, bleeding from the vagina and going into shock.

Unlike adult women, adolescents (particularly very young girls) are often not willing and sometimes not able to give an accurate history. This is especially so when they are accompanied by their parents, relatives or other persons because of fear and embarrassment at having had sexual relations.

Compared with adults, adolescents with an unsafe abortion are more likely to:

• Be unmarried
• Be primigravida
• Have a longer gestation up to the time of abortion
• Have used dangerous methods to terminate pregnancy or ingested substances that interfere with treatment
• Have resorted to illegal providers
• Come to the health facility alone or with a friend
• Delay seeking help and therefore have more entrenched complications.

It is important for primary health workers to bear in mind that unwanted pregnancy may be the real problem, though other symptoms may be reported, and they should observe the adolescent’s condition and behaviour carefully. This will assist in ensuring that the diagnosis of unsafe abortion is not missed. It would be important to employ a gentle, reassuring manner, and to tactfully ask the girl’s parents or guardians to wait outside the consulting/examining room. This will enable the health-care provider to have a private and confidential conversation with the girl.

The clinical presentation will obviously depend on the condition of the patient. In case infection has set in, the adolescent is likely to have fever and dehydration. The other likely clinical signs are: a swollen, tender abdomen, bleeding and foul-smelling discharge from the vagina, with some products of conception still in the uterus and/or vagina. In case treatment has been delayed, the adolescent is likely to be in shock with impending respiratory and circulatory failure.

The management is based on the following principles :

• Emergency resuscitation may be necessary as many adolescents present in shock. Sub-centre ANMs should refer such cases immediately to a PHC with facilities of Emergency Obstetric care (EmOc) or district women’s hospital. ANMs at PHCs with EmOc facilities can inform the doctor and other team members to provide care and/or referral to district hospital
• Evacuation of the uterus is necessary to remove all the products of conception for inevitable or incomplete abortion. Refer the client immediately to district hospital. In the second trimester, the risk of complications is higher. Because delay is so characteristic of adolescent abortion patients, many second trimester abortions are carried out in this age group.
• Management and prevention of further complications such as infection and injury is the need of the hour. Complications are more frequent and more severe in the case of self-induced abortions or those where foreign bodies have been inserted.
• Arrangements for post-abortion care should be thought of since such adolescents usually do not return for follow up. Establishing a good rapport with the patient and attendant/s and providing relevant information will facilitate a repeat visit. The patient must be given information on danger signs to look out for, such as fever and chills, nausea and vomiting, abdominal pain and backache, tenderness to pressure in the abdomen, heavy bleeding and foul-smelling vaginal discharge. She must also be provided with information on contraception for well-informed decision- making and use.

Prevention of Unsafe Abortions

Adolescent with unwanted pregnancies continue to resort to abortion, whether or not it is safe, putting their lives at great risk. Prevention of such pregnancies must therefore be one of the key objectives in any reproductive health programme.

All stakeholders like family elders and decision makers, communities, health- care providers, governments, etc should make all efforts to:

• Improve access to reproductive health information and services - The need to improve adolescents’ access to reproductive health information and services is of prime importance to give sexually active adolescents the right to a range of options. The contribution that emergency contraception could make in preventing unsafe abortion needs to be clearly spelt out and adolescents need to know that this method is available, and where it could be obtained when needed.

• Address laws and policies on access to safe abortion services -  Even in our country where abortion is legally available on demand, women (especially adolescents) experience difficulties in exercising their right to obtain these services. The reasons for this include an insensitive environment that cannot ensure confidentiality and non-judgemental behaviour, complicated administrative requirements, etc. Government authorities must emphasise the role that health-care providers have in the provision of abortion services.
• Train health-care providers in comprehensive abortion care - Health care providers need to be trained in essential abortion care so that they can recognize the signs and symptoms of abortion-related complications early and counsel for prompt and appropriate referral to a district women’s hospital or a CHC. They also need to be introduced to the concept of post abortion counselling. To be able to learn the latter, they need to examine their attitudes and beliefs, in order to prevent their own biases from hindering the provision of care.

Sources :

1. Rashtriya Kishor Swasthya Karyakram - Resource Book by Ministry of Health and Family Welfare
2. Rashtriya Kishor Swasthya Karyakram - Facilitator Guide by Ministry of Health and Family Welfare