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ABORTION METHODS, TYPES AND COMPLICATIONS (Everything You Needs To Know)

Introduction:
Among the issues many persons do not wish to discuss or listen to and some that talk about it as a rule, do so in hushed tones is abortion. The term has acquired a pejorative connotation and become so controversial, laden with emotions, superstitions, deceit and subjectivity that our society based on these information or misinformation has been divided into two antagonistic camps (the pro and anti abortion group). These emergent Polaris groups see the issue as would be expected through their vindictive lens of righteousness.

    Abortion advocates view the issue simply as a matter of choice, and an assertion peoples inalienable right to do what pleases them with their bodies. Opponents abortion rest their arguments on the proposition that the tragedy befalling these hapless “babies: is preventable in the first instance by controlling the selfish sexual practices of men and women who suddenly turn round to claim that the outcome of their action is unwanted. It is further seen as a tragedy of the equal opportunity syndrome (women liberation) whose extremists advocates are out rightly accused of double standard as they fail to uphold the rights of the unborn child.
    
     In Nigeria, while the groups differ in what they do not support, they share at least one thing in common silence. This is typically depicted by the socialization emphasis of parents on both sides of the divide. While they handle many issues of life freely with the kids, sexuality education is reluctantly touched and the mention of abortion is a real taboo. Surprisingly too, this silence conspiracy cuts across gender, ethnic, regional, religious rural, urban as well as income and educational barriers.
   
 Notwithstanding this disdain, and the ostrich display all along, the problem has simply refused to vanish. Indeed as noted Van de Walle and Meekers (1992); remains evidently in many cases, a girl’s introduction to the birth control. This ignorance betrays our claim to rationality and desire for health for all as we progress into the next century. Unfortunately still, many persons come to appreciate the problem belated in such cases as when their “wayward” unmarried daughter is found to be pregnant, their son impregnates the “bad” girl or a husband and wife “discover” that the latest  wife’s pregnancy is one too many. Face with this problem, many persons and families have been and will be thrown into serious turmoil. An unwanted pregnancy to either an unmarried girl or married woman initiates very complex crisis irrespective of whether the pregnancy ends in abortion or carried to term. It is a crisis which differs from other crisis in that our usual support systems (self. Family, friends and the community) many likely fail. 
   
   Given that the dilemma of this hideously executed biological desire of couples sometimes translates into traumatic agony, humiliation, marred career, ostracisation, psychological wreckage, broken homes, lingering guilt, litigation and if not properly managed, a knowledge of what it entails  becomes a useful guide for children, adults families and counselors irrespective of our persuasion. The knowledge may enable you to be more emphatic and to make a balanced decision tomorrow when the chips are down.                                                                 
    
 Not less important in our concern for studying this desperate but understandable alternative are such things as; apprehensions about population grown visa available resources, the unacceptably high maternal mortality and morbidity traceable to abortion, the surging wave of teenage sexuality, low rate of contraceptive use (artificial or natural), relative valuation of children which triggers sex per-selection, destabilization of traditional regimes as well as the forceful coming on stage of women liberation among others

To enhance the reader’s understanding of the problem, this chapter will succinctly examine the what, why, how where and when questions about abortion in Nigeria. This done, it is hoped, the discourse is sure to comfort the afflicted as well as afflict the comforted.
Definition:
   Abortion is the termination of pregnancy before the foetus (the newly found child) has attained viability. That is, before it has become capable of independent life outside the womb.
  
   Chances of viability depends on the duration of the pregnancy and or foetal weight. From the first day of the last normal menstrual period, viability is attained after twenty eight weeks (7 months of the pregnancy). This corresponds to an approximate total weight of 1000gram. Recent medical advance has however bettered this record, as young foetus of 500 gram weight to survive after, twenty weeks of gestation.
             Abortion is generally classified as either:
i.           Induced
ii.          Spontaneous.
  An induced abortion is the deliberate interruption of the pregnancy artificially inducing the loss of the foetus. Can be done by the woman herself or aided by other persons. It is further subdivided as legal or illegal. The legality or illegality of an induced abortion depends on the prevalent laws in a country at the time under consideration. Thus, in Nigeria, a therapeutic abortion induced in a health establishment by qualified personel(s) to save the life of the mother that would otherwise have been endangered if the pregnancy carried to term is legal. The termination of pregnancy in this type of situation based on medical advice is take to be in good faith. Outside this confinement, it is said to be illegal.
     
     On the other hand, abortion is spontaneous if it occurs naturally due to some pathological condition often beyond the control of the woman or her physician. Among the possible causes of spontaneous are trauma, high fever, infection, gross malnutrition.
   
    The incidence of spontaneous abortion can can not be established exactly as such wastage often occurs ever before a woman is aware that conception has taken place. The term abortion as used in this article refers to induced abortion either legally or otherwise.
             
  Origin of induced Abortion.
Though no one knows when the practice began human interference with and termination of unwanted pregnancy has been in practice in almost all cultures, societies and periods independently for a variety of reasons. The earliest written reference to any method of fertility control, Himes (1970) noted was, a recipe for a oral abortifacient (abortion inducing drug). This concoction which may have included quicksilver, is found in an ancient chinese medical text written by the Emperd Shen Mung in the period 2737 – 2696 B.C.
 
   Until recently, this old practice of preventing unwanted birth was one of the most hazardous and in some instances still exceed measures taken to prevent conception abinitio. Across the practicing cultures, a combination of such factors as existing laws, financially cost, accessibility, ignorance, and methods available among others have determined how a pregnancy is terminated. The use abdominal massage, herbs, catheters, toxic portions tampons, twigs, and strong purgatives are among the old ways of procuring an abortion in many areas. Purgatives and caustic douches are known to have often been administered until either abortion or death resulted (population Reports ( 1980).
    PROFILE OF AN ABORTIONIST         
What kind of girl (or woman) has an abortion? She is the woman that typically believes the foetus is nothing more than a clot of blood for at least the first few months of conception. A woman that is keen on controlling her fertility. Artificial by the use of contraceptives is sure to abort. She belongs to the clan of women that are active sexually either within or outside the matrimonial home yet or not having children; or sad and bitter when blessed when blessed with children of particular sex, merely feigning chastity. To the woman, the sanctity of life and the moral question are subsumed by the immediate personal relief  from the burden of carrying a pregnancy that is wanted.
   The potential abortion can also be a victim incest, rape (by a man man, robber etc.), underage girl, sick and emotionally imbalanced, with known hereditary disease as hemophilia in foetus, a woman of high parity who “suddenly discovers” that her latest pregnancy is one too many for the family’s capability. From this background it is evident that the woman that many go for an abortion can live in the rural or urban area, be literate or illiterate, rice or poor, of any race and tribe, and can be single or married (Devereaux 1955: chandraseckbar 1974, population Reports 1990 f, 7; Nwaokono 1985).
Incidence if abortion.
  The state of data on many basic things in Nigeria still leaves much to be desired. It is either the data is not available or when available, it may not be current and reliable. Therefore, given the illegal status of induced abortion in the country presently, the strong pro natalist traditions, the stigma associated with it which discourages those that have procured abortion is sure to be an underestimated. The situation is not different either for spontaneous abortion which are often brought to the attention of some health personnel.

  Though it is difficult to obtain national statistics, induced abortion is generally regarded as an increasing problem in Nigeria (Akingba 1972; Sai 1974; Caldwell, 1975; Mati 1977, Bakare 1978). Indeed, abortion is the most widely practiced method of fertility control by the young and old in Nigeria. For instance, of 8,400 rural women/men surveyed by Caldwell (1970), 24% admitted knowledge of either practice. Its spread can also be inferred from the survey conducted in 45 schools where it was found only 12 schools had witnessed no female student expulsion or withdrawal as a result of unwanted pregnancies or death from abortion(Akingba 1972). Yet a five year review of women treated in one Nigeria hospital for abortion related cases found that over 90% were single and mainly adolescent girls (Akingba 1974. P 14).

In recent times, available estimates on maternal mortality show an unusually high rate of casualty. On the average, about 75,000 die annually in Nigeria as a consequence of conception (Adindu – Okeke 1990, FGN 1991, UNICEF 1991). This of course includes unreported deaths in the homes, patent medicine stores, prayer houses, herbal homes and ‘’clinics’’ among others. A lather disproportionate of this proffered mortality figure come from abortion related cases (Population Report 1996 Series E, p. 27). This is not unexpected as one out five secondary school girl in Nigeria has had an induced abortion before leaving college (Eshiet 1996). The high incidence of adolescent premarital sex and pregnancy are attributable to the following:
i.  Early maturity of the adolescents. 
ii.Urbanization and lifestyles associated with it which provide more opportunities for sexual relationships while reducing the effectiveness of traditional social restraints.
iii. with early sexual maturation and increasing age at marriage due to such things as high cost of marriage, prolonged stay in schools, the period of non marital fecundity is extended.
                                                                                                                                                                                                                                
 METHODS OF ABORTION
There are large numbers of clients, providers and also methods. These ranges from the old miserable and outrightly dangerous ones to the modern and ‘’safer’’ scientific methods. The modern methods used by physicians presently for the termination of pregnancy can be conveniently discussed under three headings:
i.           instrumental evacuation
ii.          stimulation of uterine contraction
iii.         major surgery
i.           Instrumental Evacuation
  This is carried out by the vaginal route under general or local anesthesia. It is used primarily for the termination of pregnancy in the first trimester (first three months), although it can be done in the fourth of gestation (13-16 weeks).
These include;
a)The more common method usually referred to as dilation and curettage (D and C). it involves the use of ovum forceps to scrape gently the embryo and placenta dislodging them from the womb after dilating the cervical canal. Could be traumatic and involves loss of blood. 
While the curettage (scraping) is not painful as there are no nerve endings in the uterus, dilatation of the cervix is painful, hence the need for anesthesia. The operation is normally completed in about fifteen minutes and the patient is up after few hours.
   Dilatation and curettage (D&C) can be used for medical operation other than the termination of a pregnancy. For instance as a means of introducing radium into the cervix or uterus for treating cancer preliminary step to curettage of the uterine cavity of diagnosis or an integral aspect of other operations on the cervix such as amputation (Howkins and Stallworthy 1974, Telinde and Mattingly 1970).
b) Suction (Vacuum aspiration)
    This is also done under anesthesia. After dilation, a cannula and pump are used to dislodge the embryo from the womb. It is simpler, quicker and involves less blood loss (Beric and Kupresannin 1971). A variant of the vacuum aspirator is called menstrual regulation (MR). or endometrial aspiration. This is used in the first few weeks after missed menstrual period. It is not always possible to know if the women are pregnant prior to examining the aspirated uterine contents. 
ii.Stimulation of uterine contraction: During the second trimester (between 4-6months) of pregnancy, its termination is initially initiated by the stimulation of uterine contractions. The procedure includes;
a.The replacement amniotic fluid by hypertonic salt solution: It is generally done anesthesia. Involves the replacement of about 200 milligrams of fluid from the womb with either an equal or bigger amount of saline, Urea or hypertonic glucose solution. A few minutes labour begins within 12-48 hours of the fluid replacement and the foetus is expelled shortly afterwards.
b. Uterine contraction can equally be achieved by the instillation of small quantities of medicated pastes or hypertonic saline between the membrane and the womb wall through a rubber tube membrane and the womb wall through a rubber tube called catheter.
c.The most recent addition to the technique of stimulation of uterine contraction are the prostaglandins. This is injected in single or multiple doses without replacement of amniotic fluid. The period between injection and actual delivery is shorter with prostaglandins than with hypertonic saline. It should be noted that with all extra-amniotic methods, most babies are delivered alive but die shortly afterward (Tietze and Dawson 1973).


b)  Surgical procedures
        a. Hysterotomy
        b. Hysterectomy
      These are cesarean section at any stage of pregnancy before the fetus is viable. The operation can be done till the 16 week by the vaginal route, otherwise the uterus is approached by laparotomy. As the scar in the womb wall is believed weaken the tissue and can cause rapture of the womb at later delivery, many practitioners fear that all subsequent pregnancies will require another cesarean section. Because of this, the operation is performed only if further pregnancies are not desired.

Hysterectomy:- This is a sterilizing procedure done under general anesthesia. It is often performed when the objective of the operation is the removal of the uterus because of fibroid tumors, in addition to the termination of pregnancy. 

Local Methods:
Irrespective of costs and legal status of abortion some persons resort to the use of traditional methods for terminating unwanted pregnancies in many of the developing countries. These include the insertion of foreign bodies as twigs and roots in the vaginal, drinking of herbal mixtures, herbal purgatives, abdominal massages, incantations and spells among others. The efficacy of each of these traditional methods is not certain. One thing known is that irrespective of the method use in terminating a pregnancy, the exercise is a stressful experience involving major risks to the physical and mental health of the woman involved. Even when performed by a physician, abortion may have such adverse efforts as subsequent.

Cost of Abortion.
Whereas the cost of normal delivery in many standard hospitals in Nigeria is high, the cost of procuring abortion is relatively low. The amount charged at the many centres that offer these services often range from five hundred naira to a few thousand Naira. There are however other costs to the individual and society.
 
Induced abortion, at the period of gestation, exposes the woman to the risks of complications. Undoubtedly, many women are not aware of the dangers associated with induced abortion, while others face the dangers knowingly desperate to avoid an unwanted birth. For the individual woman, the risks and costs are high and beyond the “few” Naira paid to the abortionists. The community also bears far reaching human and financial burdens for each abortion performed. Such consequences can be divided into two morbidity and mortality categories depending on when its effect manifest. Thus, we have the immediate and late complication groups.

Immediate Complications. 
These occur within a few hours not later than 30 days after the fetus has been removed, and may not even be noticed. It includes; perforation of the uterus by one of the instruments used in vaginal evacuation, sometimes combined with injury to the intestine or other organs. There are also the problems of major hemorrhage, laceration of the cervix, effects on type central nervous system and or kidney resulting from hypertonic salt solution entering the blood stream directly or through particle cavity, the untoward effect of general or local anesthesia and shock. Others are incomplete abortion, retentions of fragments of the placenta resulting in postabortal bleeding, tetanus, postabortal depression and guilt feelings among others.

Late Complications. 
Normality occurs after 30 days of the operation. Known late complications include effects on later pregnancies such as increasing the chances of pre-mature birth, endometrium neonatal mortality, miscarriage especially between 4-6 months second trimesters. The later may be due to a combination of factors such as due to much scraping of the basal layers of the damage to the cervix at the time of dilation and placenta insufficiency.
 
Others are; low birth weight of infants, secondary sterility and ectopic pregnancy (conception outside the womb) chances of sensitization Rh-negative women by red blood cells from Rh-positive foetus.

Abortion and Mortality. 
In Nigeria, where vital registration (simple records births, death, marriages, divorces and adoption etc) is still a novel idea it may seem unreasonable to expect accurate official figures on mortality due to abortion. National statistical year books do not contain it. However, on the strength of information from scattered sources such as ad hoc surveys and hospital statistics, there is no doubt that induced abortion is a major of maternal mortality in the country.
 
  In a research on maternal death conducted at the Lagos university teaching hospital (LUTH),it was found that 51% maternal deaths in the institution were as a result of abortion complications.  Reinforcing this are the more recent findings by who observed that not less than 75000 Nigerians women die each year due to complication from abortion.

Other cost of abortion.
      In addition to the direct monetary cost to the woman, which payment can create enormous personal hardships, are the cost of transportation to and from the abortion centre, cost of drugs to alleviate subsequent complications. The woman also losses income for missing work, she also suffers from guilt among other feelings.
The burden of abortion does not end with the woman, as the family, medical institution and the community are not left out, the immediate family suffers in terms of the loss of the woman’s service for the period of hospitalization, permanent loss if she dies and grief.

Cost of medical establishment
  Abortion complication accounts for a significant  proportion of hospital admissions in many parts of the world, patients usually spends up to 7 days or more at the hospital depending on the severity of the case. Many hospitals lack resource to provide adequate care to these patients in addition to patients having normal deliveries and other needs.

Hospitals are hard pressed to sort for blood which is very costly and in short supply to treat hemorrhage (excess bleeding), which is a major complication of induced abortion. Very costly equipment and supplies are needed to treat severe cases. Yet, there is need for using more personnel and time on each case.

By
Umoh BD
Enugu State University Of Science And Technology





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