Induced Abortion: Any Need for Resentment?
Author:
Introduction:
Abortion, whether induced or spontaneous, is the termination of pregnancy before the viability of the fetus(usually,20-28 weeks gestation and/or a mass of 500g)1,2. It is a phenomenon that cannot be wished away. Its apparent inevitability has necessitated various jurisdictions adorning it. Despite restrictive laws in many nations, it is carried out on a daily basis, albeit, in unsafe ways.3-5.
Initiation of sexual behaviour is a normal part of human development and often occurs in adolescents,6 whose innate environmental and humoral influences encourage sexual activities. Adolescent sexuality and its sequelae are now acknowledged as a major public health, social and economic problem. Poor knowledge of reproductive biology and poor contraception predispose them to unwanted pregancy.7, 8
Abortion is among the top five causes of death; only second to puerperal sepsis.9 No issue in medical practice, has in recent time, as abortion, generated such magnitude of controversies, with protagonists and antagonists alike postulating points which surprisingly border on women\'s health and reproductive right.
Induced Abortion:
Abortion can either be spontaneous or induced 1,2. Spontaneous abortion can be threatened, incomplete or complete, inevitable, missed, septic or habitual/recurrent. Habitual abortion is usually due to a developmental anomaly.10
Induced abortion is the leading cause of maternal mortality in most developing nations.6,11,12. Its criminalization has contributed more to this.13. Unsafe abortion in Africa has grave implications, not only for the woman and her future reproductive career, but also her children, family and the community.14,15. Induced abortion represents a serious threat to women\'s health and lives.
Since these terminations are in secret, many crude methods are adopted,16-18 ranging from the use of local herbs, instrumentation (dilators and uterine sound), purgatives, alcoholic drinks, caustic agents, to dilatation and curettage, suction and evacuation.
It is amusing to note that a histopathologic report19 indicated that a significant proportion of women seeking abortion services are not pregnant. This, underscores the over zealousness of the operators and puts to question their qualification and training.
Epidemiology:
Unintended pregnancy is a major reproductive health issue, especially among teenagers. Teenage pregnancy, itself, is associated with age, occupation and little or no education.20, 21. The most affected age group is 15-19, 21-22 Single women and widows; women in polygamous marital relationship, lower parity, with lower education and number of living children; and women with a recent history of domestic violence present for abortion 16,18. Although majority of induced abortion were done by the unmarried age group, married women constitute a significant proportion while students top the chart23.
Why Induce Abortion? 18,23, 24.
Different views quickly come to the fore as to the reason why abortion is induced. Generally, pregnancy is unplanned and therefore unwanted. Others include educational considerations, threat to mum\'s life; severely malformed baby; parental incompetence; family\'s name and integrity; disputed paternity; personal desire not to have children; baby\'s sex; high cost of raising children; short birth interval; out of wedlock sex; cases of rape or sexual abuse; failed contraception; socio-economic consideration and having too many children. These reasons broadly define the categories of abortion seekers.
Protagonist Views (In defence of Abortion).
There are healed debates among health-care providers, advocacy groups, policy-makers and legislators in many developing countries where there are restrictive laws on abortion.14, 25-27. This has made some countries to shift grounds (permitting abortion) 28-30; make some modifications13 or remain indifferent.31
The reasons, in defence, include:
a. Safety: Abortion is one of the safest medical procedures that if allowed will greatly prevent abortion-related death and injuries which are tragic and easily preventable. 14,31, 32.
b. \'Feminism\': Protagonists of this idea believe that male superiority framed the morality, legality and socio-cultural attitudes towards abortion and has denied it as an important status.25,27,31.They propose that women reclaim their power to choose, including access to safe abortion services as this violation of women\'s reproductive rights is both a cause and manifestation of women disempowerment.
c. Decrease in maternal mortality: The introduction of Termination of Pregnancy (TOP) act in many developing countries has been associated with massive reduction in maternal mortality ratio (MMR). The involvement of midwives in abortion care has created access to women in remote rural areas.28, 29
d. Outdated laws and customs13, 26: This view believes that traditional and cultural values, social perception, religious teachings, remnants of former colonial laws have facilitated stigmatization of abortion and its practitioners. It proposes that in line with recent advancements in technology, that the issue be approached from the perspective that emphasizes the individual\'s right to self-determination.
An Antagonist\'s View
Opponents to induced abortion have presented facts, which unveiled the grave consequences that follow this act.
These include:
a. Breast Cancer: Strong emerging evidences posit an increased breast cancer risk following abortion just as in those on postmenopausal hormone replacement therapy.33
b. Post Abortion Syndrome (PAS): This is the emotional, psychological, physical and spiritual trauma caused by an abortion, which is beyond the normal range of human experience34. It is a post traumatic disorder characterized by a stressor (abortion) and physical symptoms such as insomnia and depression, one out of every three patients presenting after an abortion fulfills this criterion.
c. Infection: This ranges from the rare septic sacroilitis35, to common ones as post-abortal broad ligament abscess36 and sepsis 12, 37-39. This usually follows the use of unsterilized equipment and an unhygienic operating environment.
d. Damage to the visceral organs: This includes bowel injury40, and the perforation of the uterus (mostly at the fundus, followed by the posterior, anterior and lateral walls) 22.
e. Haemorrhage: This, in the acute phase, could lead to shock, renal shut down or to anaemia in the long run. It follows the use of sharp objects, herbal medications (leading to endotoxaemia), cervical / vaginal lacerations, excessive endometrial curettage and incomplete abortion15, 39.
f. Increased maternal mortality rate (MMR): Abortion is the second leading cause of maternal death (second to haemorrhage). 38, 41-43
g. Secondary Infertility: This is the commonest late complication of induced abortion. The fertility rate decreases with increasing number of abortions39, 44. This, in part, is accounted for by structural damage to pelvic organs and chronic pelvic infection.
h. A case has been reported of mid-trimester induced abortion using traditional method, which resulted in uterine inversion45. Also, a high prevalence of Chlamydia trachomatis infection is associated with people presenting for TOP46.
Conclusion / Advocacy
Weighing the pain and gain of abortion is of paramount importance. The points in favour and against induced abortion, irrespective of the laws and the practitioner centre on women reproductive health. Admittedly, all agree that the legalization of abortion in some countries has not affected its incidence or complications arising therein. This, once again, brings to the fore the need for African nations to understand their root and cherished age-long concept of the family.
I therefore, in agreement with some researchers, advocate for the following:-
1. Primary prevention which includes appropriate sexuality education and secondary prevention efforts to prompt diagnosis and treatment of complications, including contraception and other elements of life planning. Parental supervision and proper education of adolescents in goal-setting, decision-making and good value system is strongly advocated in line with African\'s concept of the family6, 7.
2. Training\retraining of medical and healthcare professionals to increase awareness of contraception its options, timing, available methods and usage; safer sex practices; post abortion care; and expanding access to family planning, counseling and quality care 6,15,39,42,47-50.
3. Enactment of laws to make adoption of unwanted children easy51.
4. Ensuring that research results are shared with appropriate decision-making bodies so as to affect policy and programme advocacy52.
Prevention still remains the key. Abstinence among the teenagers and unmarried; and the appropriate use of contraceptives will lessen the burden. Lack of facilities, access and manpower still pose a great challenge. The thought that the proponents of induced abortion are those already born (not aborted) indeed, calls for sheer resentment.
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Correspondence:
Dr. Anyanwagu Uchenna Chidi
uceeanyanwagu@yahoo.com