By: 1. Ahadu Workneh - PowerPoint Presentation

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By: 1. Ahadu Workneh (MD, Assistant Prof.Gyn/Obs)2. Yibeltal Siraneh (PH,MPH/HSM, PhD Fellow) JUIH *TM-MA, JUMC-Trimester Medical Abortion at Jimma Univeristy Medical Center

Determinants and Outcome of Safe 2nd TM-MA, JUMC*

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

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Background 2nd TM Abortion is termination of pregnancy during 13 to 28wks of GA (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 proportion of 2nd TMA are few as compared to 1st TMHowever 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 was34% in Kenya,30% in India 25% in South Africa11% in Ethiopia, 10% in Nigeria , and 8.6% in England and Wales, (Susheela Singh...et al,2008) In Ethiopian case,Amhara Region’s prevalence of 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)

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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 200841% 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 bodyAbortion-related deaths accounted for more than 30% of maternal deaths, from w/c 11% was due to 2nd TMA

(

FMoH

HSDPII,

FMoH

, 2006 report) 4

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Rationale/Justification1. 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 But abortion performed 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

w

hether end up with complication or not!

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I

n fact, determinants of abortion (reasons why terminated and delayed?) was assessed elswhere but not specific to outcome of safe 2nd TM-MA 2nd TMA, an inherently more risky procedure, reasons why women delay seeking an abortion until the 2nd TM? Should be also studied (Jane Harries...et al,2010)5

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Significance of the studyWill 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 JUMCIndentfying 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 6

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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 affect outcome of safe 2nd TM-MA

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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 that 180 women were admitted for safe 2nd TM-MA over a period of 6 months from previous year recordsAverage rate of adimission was 30 clients/month---1/day

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Operational definitionComplete abortion without complication Expulsion in a reasonable period of time (after starting regimen within 48-72 hrs, using the protocol of the hosppital) without any complicationIncomplete abortion with 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 towards abortion was measured by using 5-point likert scale 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. Satisfaction on 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 client

s 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-disatisfi

ed and

scored mean

val

u

e

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 failure means 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.

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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 More than three fourths 159 (79.1%) had a monthly own income of 0 to 22.22USD, ranging from 0 to 133.33 USD. Annexed Tables-Abortion.pdf (Refer to Table 1) 12

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Outcome of Safe 2nd TM-MA Majority 100 (59.8%) were b/n 12-18wks of GA , and 3/4th of them were Gravida IHemoglobin (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 complicationFor 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)

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@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 had one & 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

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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 of minor 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

%

) and

re-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. 14

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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 to requesting an abortionWomen’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 cancelling appointments) (Roger Ingham

....et al,2012)

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Predictors of Outcome of Safe 2nd TM-MAFrom the 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 having complete 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 ha

d complete abortion without any complication

as compared to those whose gestational age was between

12-18weeks.

Multipara

women 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 16

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Predictors...The odds of increased overall waiting time will decrease the 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)] were less likely to had 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 with induced 2nd TM

abortion

Unwanted

Pregnancy [OR] 10.45, 95%

; [CI] 3.59–30.41) Living in a household headed by parents (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 maternal characteristics into consideration (parity, race, marital status, previous deliveries) The younger age group (<35years old) who were at an earlier gestation age (12 to 16 weeks) are more likely to need evacuation of uterus to complete the termination (Yong, a kale, r mary,2010) In Jimma 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 a pregnancy, drug trial and failure, previous experiences, contraceptive history) Health service related barriers (quality, non-client centered service) (Jane Harries...et al,2010/)17

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Bivariate and Multivariable LR18

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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. 19

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Conclusion and Recommendation This finding implied that 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 exceptions of legal implication.

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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 21

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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 2Shah I, Ahman E. Unsafe abortion: global and regional incidence, trends, consequences, and challenges. J Obstet Gynaecol 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):60–65Zeba Sathar, Susheela Singh, Gul Rashida, Zakir Shah, and Rehan Niazi, 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. Acta Obstet Gynecol 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 2014:6 565–572Ethiopian 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 pageRoger 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 Ivalu Bonnen, Dereje Negussie Tuijje and Vibeke Rasch, 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) 14:416Jane 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:10.1186/1742-4755-4-7Grimes 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

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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):1848–1849.22

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“....No Women will die while she have the right to SRH....”!!! THANK YOU! 23