Abstract
ObjectivesTo describe the magnitude and severity of abortion-related complications in health facilities and calculate the incidence of abortion-related near-miss complications at the population level in three provinces in Zambia, a country where abortion is legal but stigmatized. Study designWe conducted a cross-sectional study in 35 district, provincial and tertiary hospitals over 5 months. All women hospitalized for abortion-related complications were eligible for inclusion. Cases of abortion-related near-miss, moderate and low morbidity were identified using adapted World Health Organization (WHO) near-miss and the prospective morbidity methodology criteria. Incidence was calculated by annualizing the number of near-misses and dividing by the population of women of reproductive age. We calculated the abortion-related near-miss rate, abortion-related near-miss ratio and the hospital mortality index. ResultsParticipating hospitals recorded 26,723 births during the study. Of admissions for post-abortion care, 2406 (42%) were eligible for inclusion. Near-misses constituted 16% of admitted complications and there were 14 abortion-related maternal deaths. The hospital mortality index was 3%; the abortion-related near-miss rate for the three provinces was 72 per 100,000 women, and the near-miss ratio was 450 per 100,000 live births. ConclusionsAbortion-related near-miss and mortality are challenges for the Zambian health system. Adapted to reflect health systems capabilities, the WHO near-miss criteria can be applied to routine hospital records to obtain useful data in low-income settings. Reducing avoidable maternal mortality and morbidity due to abortion requires efforts to de-stigmatize access to abortion provision, and expanded access to modern contraception. ImplicationsThe abortion-related near-miss rate is high in Zambia compared with other restrictive contexts. Our results suggest that near-miss is a promising indicator of unsafe abortion; can be measured using routine hospital data, conveniently defined using the WHO criteria; and can be incorporated into the frequently utilized prospective morbidity methodology.
Highlights
We introduced anemia into our classification because hemorrhage is a major complication of unsafe abortion [25], but the prospective morbidity methodology (PMM) does not include in its categories criteria other than shock to assess severity of blood loss
We extended the PMM framework by introducing a near-miss category based on standardized World Health Organization (WHO) criteria and incorporating anemia in all the categories
The frequency of abortion-related near-miss morbidity and mortality suggests that access to abortion services in Zambia remains poor despite the favorable liberal abortion law
Summary
To describe the magnitude and severity of abortion-related complications in health facilities and calculate the incidence of abortionrelated near-miss complications at the population level in three provinces in Zambia, a country where abortion is legal but stigmatized. All women hospitalized for abortion-related complications were eligible for inclusion. Cases of abortion-related near-miss, moderate and low morbidity were identified using adapted World Health Organization (WHO) near-miss and the prospective morbidity methodology criteria. We calculated the abortion-related near-miss rate, abortion-related near-miss ratio and the hospital mortality index. The hospital mortality index was 3%; the abortion-related near-miss rate for the three provinces was 72 per 100,000 women, and the near-miss ratio was 450 per 100,000 live births. Adapted to reflect health systems capabilities, the WHO near-miss criteria can be applied to routine hospital records to obtain useful data in low-income settings.
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