Choosing to have an illegal abortion in southern Africa: a comprehensive systematic review of the qualitative and text and opinion evidence.

Abstract

JBI Centre Wits Centre for Evidence-Based Practice: an affiliate centre of the Joanna Briggs Institute Centre for Health Science Education University of the Witwatersrand Parktown, Johannesburg South Africa Background The Choice on Termination of Pregnancy Act (Act 92 of 1996) replaced the Abortion and Sterilization Act (Act No 2 of 1975). The Abortion and Sterilization Act allowed for termination of pregnancy for specific reasons and conditions. The current Act of 1996 allows for termination of pregnancy at the mother's request up until the 12th week of pregnancy and under specific conditions up to and including the 20th week of pregnancy. In the year 2000, the rate of hospital admissions from unsafe abortion, deduced from complications of incomplete miscarriages, in South Africa was 4.8 per 1000 women aged 15 - 44 years. A reduced infection rate and maternal mortality after the liberalization of the TOP law was also reported. 13 The existence of legal abortion does not mean that the abortion is safe. Although the overall abortion rate has been reported to decline from 1995 to 2003, the proportion of unsafe abortion is on the rise from 44% to 48%, especially in the developing countries. 14 The unsafe abortion / illegal abortion is a procedure to terminate an unwanted pregnancy performed either by individuals lacking the necessary skills or in an environment that does not have basic medical standards or both. In 2000 it was estimated that, worldwide, of 46 million abortions performed annually, 19 million are unsafe. The burden of unsafe abortion is highest in Africa.1 In 2004 it was reported that some 68,000 women die each year as a result of unsafe abortion and 5.3 million suffer disability.2 WHO believes that unsafe abortion is one of the easiest preventable causes of maternal morbidity and mortality.3 In South Africa, legal TOP is provided on request up to 20 weeks of gestation. Annually about 40,000 induced termination of pregnancy are performed under the liberal “choice of termination of pregnancy act” (CTOP) 1996, South Africa (SA).10 A study done in South Africa in 2000 reported data on all women (761) who presented with incomplete miscarriages up to 22 weeks of pregnancy over a 3 weeks period in 47 public hospitals. The incomplete miscarriages included both “unsafe abortions” and incomplete abortions from spontaneous miscarriages. Most of the women (67%) presented in the first trimester. Presence of septicaemic shock and generalized peritonitis was very low (<1%) although some women (13.5%) had an offensive discharge and 8.5% experienced a tender uterus. The incidence of organ dysfunctions such as disseminated intravascular coagulation, respiratory distress, hypovolaemic shock and renal failure, which were based only on clinical examinations, such as were also very low. It must be noted that because specific diagnostic blood tests were not done in this study, the low incidence reported in this study, may be an underestimation. There were no pelvic organ injuries mentioned and the genital injuries were also very low (<1%). Blood transfusion and antibiotics were given to 8% and 33.5% of the women respectively. The study concluded that morbidity from illegal TOP has decreased after legalization of abortion in SA. This study excluded the legally induced abortions and did not specify the complications of the women who presented after having an abortion performed outside of a health care facility. The evidence of Misoprostol (A Prostaglandin E1 drug, used to terminate pregnancy in the first and second trimesters of pregnancy or induce labour in late pregnancy use was also very low (<1%).11 Another study done in the year 2000 in South Africa on 46 women who disclosed having had a TOP outside of a health care facility and who presented to the hospitals with incomplete miscarriages, attempted to find the reasons for women seeking TOP services outside of health care facilities. This study reported that 24% of TOPs were done by traditional healers, 11% by doctors, 4% by Nurses, 4% by pharmacists and 42% of the women had induced the TOP themselves. The study used a questionnaire to survey the women who presented with incomplete miscarriages. No other complications were included in the study.12 A recent large study in South Africa reported a lack in the provision of TOP services and the failure to meet the rising demand for TOP in the Johannesburg district health facilities over a period of 2 years. The study warned that unsafe abortion might be on the rise due to failure of service provision.15 A 2004 retrospective study including all admissions from complications from termination of pregnancy (TOP) in India, over a period of 15 years, the rate of unsafe abortion was reported to be 5% of the total emergency Gynaecological admissions. Among 323 women, 7% were adolescents, 3% were beyond the legal cut-off gestational age of 20 weeks. Medical doctors provided 39% of the TOPs. Others were provided by traditional healers (32%), unqualified (57%) and non-medical persons (16%). Dilatation and Evacuation (D&E) was the commonest method used to perform the TOP. Organ injuries occurred in 52% of the women and 25% women died. The management and the final outcome of the women in the hospital were not discussed in the study. India has had a liberal TOP law for many years.4 In a recent study conducted in Pakistan over a period of one year and which included 50 women who had had an induced abortion, 84% were at 12 weeks or less. Dilatation and Evacuation (D & E) was the commonest (56%) method of termination. The majority (76%) of the women presented to hospital after 24 hours of attempted TOP. Uterine injury and bowel injury occurred in 30% and 24% of the women respectively. Life-saving hysterectomy was required in 4 (8%) women. Six (12%) women died due to septicaemia. The majority (72%) of the TOPs was provided by medical doctors and trained female health personnel and 18% were provided by nurses and traditional birth attendants. No TOPs were performed by non-medical persons or were self-induced.5 In a 2005 Kenyan study on complications of incomplete miscarriages among 809 women admitted to selected hospitals over a 3 weeks period, 16% were adolescents and 24% were primigravidae. Most of the women (66%) presented in the first trimester and the commonest (80%) presenting complication was retained products of conception (RPOC). Nine (1%) of the women had organ injuries and 34 (4%) women had sepsis. Two women underwent life-saving Hysterectomy and 7 women died. This study was unable to specify the complications particularly arising from unsafe (illegal) TOP, because many of these women do not suffer complications and therefore do not present to health facilities. The study included all women who had had miscarriages, and did not distinguish between the induced termination of pregnancy and the spontaneous miscarriage.6 Similarly, in a Zimbabwean study that analysed the complications of an induced abortion among 355 women over a 6 months period, 15% were teenagers and 2% were primigravidae. The mean gestational age at presentation was 11 weeks. The commonest (73%) presenting complication was RPOC. Four (1%) women died.7 In a multi-centre Ugandan study, a total of 110,000 women were treated for complications of induced abortion in the year 2003. The rate of abortion complications was 20 per 1000 women aged 15 - 49 years. Although the study reported morbidity due to unsafe abortion to be very high in Uganda, the detailed nature of the complications and their management outcome were not discussed in this study.8 Similarly, a large study in Nigeria reported 34% fever, 21% pelvic sepsis, 11% instrumental injuries and 2.4% death among women who presented to hospital after attempting an induced abortion outside the hospital. 9 The Cochrane Library, Joanna Briggs Institute (JBI) and CINAHL database have been searched and no previous systematic reviews on this specific topic were identified as being published or underway. Review Objective/Questions The overall objective of this systematic review is to critically appraise, synthesize and present the best available evidence in relation to why women choose to undergo an “illegal or unsafe” abortion when abortion is legal and readily available in South Africa. Review question: Why do pregnant women choose “illegal or unsafe” abortions when legal abortions are freely available in South Africa? Keywords: childbearing women, illegal abortions, unsafe abortions, backstreet abortions, qualitative research, South Africa Inclusion Criteria Types of participants This systematic review will consider any qualitative study where the focus is on pregnant women of childbearing age who have had an illegal abortion and who live in Southern Africa. Phenomena of interest The phenomena of interest of this review are the reasons why women choose illegal abortions in situations where abortion is freely available; social and demographic data of participants in studies. For the purpose of this systematic review, studies that use terms such as “unsafe” abortion, or abortions conducted in “non-medical settings” will be considered to be illegal abortions and will be considered for inclusion in the study. Context This review will consider any qualitative study for inclusion that was conducted in South Africa. Studies that have been conducted in public or private health care settings will be considered for inclusion in the review. Health care settings may include hospitals, clinics and non-governmental organizations that offer supportive services to women who have had an abortion. Types of studies: This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. This review will also consider non-research papers such as text and opinion papers and reports. Search strategy The following initial key words will be used: childbearing women, illegal abortions, unsafe abortions, backstreet abortions, qualitative research, Southern Africa a limited search of Pubmed and CINAHL to identify relevant keywords contained in the title, abstract and subject descriptors terms identified in this way and the synonyms used by respective databases will be used in an extensive search of the literature. Databases to be searched in this stage include SABINET, Scopus. reference lists and bibliographies of the articles chosen from those identified in stage 2 will be searched Grey literature identified through reference lists will be searched and where African journals of health care are not identified in databases, appropriate hand searching will be done. Assessment of methodological quality All papers selected for inclusion in the review will be subjected to a rigorous, independent appraisal by two critical appraisers to identify and select papers of the highest quality, i.e. that minimise bias, and have good internal validity. Assessment of Methodological Data Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Qualitative Evidence Data Extraction Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute - JBI-QARI (Appendix III) The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives. Data Synthesis Qualitative research findings will, where possible be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Textual Evidence Data Extraction Textual data will be extracted from papers included in the review using the standardised data extraction tool from JBI-NOTARI (Appendix IV). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives. Data Synthesis Textual papers will, where possible be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorising these conclusions on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative form. Synthesis of evidence into evidence statements Synthesised findings will be graded according to the JBI levels of evidence FAME scale (Feasibility, Appropriateness, Meaningfulness and Effectiveness) developed by JBI (Appendix V).16 It is anticipated that the bulk of the research on this topic will be of a qualitative nature; hence the direction of the synthesis would be for Meaningfulness. Conflicts of Interest None to declare