INTRODUCTION

World widely, it is estimated that about 20 million unsafe abortions occur each year with consequent complications or irreversible sequelae, contributing to the increased maternal morbidity and mortality¹. FNine out of every thousand women aged between 15 and 44 years were hospitalized for abortion in 2005². The treatment for complications related to unsafe abortion, hospitalizes five million women every year. Among the main complications related to unsafe abortion are: hemorrhage, infection, sepsis, and genital trauma³.

These complications are among the leading causes of death in women in Brazil, due to the existence of restrictive laws, abortion is often performed in precarious conditions of service⁴. Although it has been observed a decrease in the rates of morbidity and hospitalization for abortion since the 90's, this decline was more evident between 1992 and 1995, coinciding with the popularization of the use of misoprostol in place of unsafe methods more invasive⁴. Despite the decline observed in the 90's, the complication rates of induced abortion has varied little since then and still are unacceptable levels¹ In Recife, Northeast of Brazil, the treatment for abortion complications represented 21% of the total hospital admissions in the period of 2003 to 2007⁵. Unsafe abortion and its complications are a serious public health problem in Brazil and in most of Latin America, and its solution remains a challenge that goes beyond the process of legalization⁶. Considering the impact of abortion in the context of public health, especially its complications and sequelae, this study aimed to describe the sociodemographic and reproductive profile of women with complications of abortion in a hospital in the city of Recife between 2008 and 2010.

METHODS

A descriptive cross-sectional study was conducted at the Instituto de Medicina Integral Prof. Fernando Figueira(IMIP). The sample was composed of 122 medical records of women who had any abortion complication among all 569 women admitted with abortion diagnosis, between January 2008 and December 2010.

Women admitted with a diagnosis of abortion have been identified through patient's file on obstetric emergency and by patient's files. Women with gestational trophoblastic disease, ectopic pregnancy and incompetence isthmus-cervical were excluded from the study. The abortion complications were considered:infection, use of antibiotics, blood transfusion, Intensive Care Unit (ICU) admission, surgical interventions, uterine perforation, shock (septic and/or hypovolemic), sepsis and death.

Data were collected using an instrument specially designed for this study including information about sociodemografic, reproductive and clinical variables in the medical records. The data analysis was performed by using Epi-Info 3.5.3 software. The absolute distribution and relative frequencies of the variables were described on a table and a graph. The project was approved by the Ethics Committee and Research of the IMIP under the number 2332/11. The term of consentment was dismissed because the data was collected from secondary sources (medical records).

RESULTS

Among the 569 medical records, 122 were found with abortion complications. The prevalence on complications corresponded to 21.4% (CI: 18.2 - 25.1%), in the period of January 2008 to December 2010. To analyze the rate of complications every year, there was no variation in the period studied. The prevalence on complications was 21.4% in 2008, 21.0% in 2009 and 22.0% in 2010.

Regarding to the clinical form of abortion at the time of the discharge, there was a predominance of infected abortion (70.5%) followed by incomplete abortion (22.1%), inevitable abortion (5.7%) and retained abortion (1.6%).

Table 1 presents the sociodemographic and reproductive women profile with abortion complications. 73.0% were between 20 and 35 years, and the adolescents accounted for 18% of the sample. The mean age for women was 25.3 years (SD: 6.6). In relation to schooling, it was observed that more than half had more than eight years of studying (55.8%). Half of the women were married or lived in a stable relationship, were unemployed and the majority (77.8%) of the women was from Recife and the Metropolitan area of Recife. In relation to the number of previous abortions, 75.4% of the women had no previous abortion. According to gestational age, the incidence of complications was higher among the late abortions or above 12 weeks of pregnancy (46.7%).

Table 1. Sociodemographic characteristics and reproductive traits of women hospitalized with abortion complications in IMIP, Recife, Pernambuco, in the period of 2008-2010.

Among the complications the infection was highlighted in 77.0% of the cases.The need for blood transfusions was 15.6% of the cases. Also, 12.3% of the women were admitted to ICU obstetric at IMIP, 8.2% had septic shock and/or hypovolemic (five cases of septic shock and five cases of hypovolemic shock), 2.5% of the women had sepsis related to abortion and 4.9% died. There were also four surgical interventions (two cases of laparotomy, one hysterectomy and one correction of vaginal lesion). In one of two cases of uterine perforation, the surgery was not performed because she passed away before the procedure. (Figure 1).

Figure 1. Distribution of abortion complications. IMIP, Recife, 2008-2010.

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Figure 1. Distribution of abortion complications. IMIP, Recife, 2008-2010.

DISCUSSION

This study found a rate on abortion complications similar to the city of Campinas, Brazil (23.5%)⁷ and in Nigeria (24%)⁸. It was observed in Thailand, a rate a bit higher with a percentage of 36.8%⁹. Such high rates on complications are found in countries where abortion is considered illegal, motivating women to use unsafe methods to interrupt an unwanted pregnancy¹⁰.

In this study, the complications were more frequent in women in the age group between 20 and 35 years, and this has been the age range most observed in the majority of studies on abortion complications in different regions^9,11. In general, this is the predominant age group mostly studied on abortion or problems related to pregnancy, as it is considered the ideal age for reproduction.

Schooling usually was used as a proxy in a socioeconomic status and in this study the majority of women had over eight years of schooling. This may reflect to the Brazilian population as having better education, in contrast with the situation of countries on the African continent where the access for women to education is still restricted¹². A review on studies on induced abortion in different countries has showed predominance in women having more than eight years of schooling¹³. Women with more education may be motivated to stop an unplanned pregnancy and invest in their education or professional growth. On the other hand, in Pakistan about 60% of women hospitalized for treatment on unsafe abortion complications had no instruction¹².

Women were mostly from the metropolitan area and Recife concordant with the study to focus on abortion demographically in Brazil which also showed a predominance of women from the urban zone⁶. Generally women who live in large urban centers have greater access to abortion methods, abortion clinics as well as to health services¹⁴.

Most of the women in this study had no previous abortion and this also occurred in another study at the same service between 2008 and 2010¹⁵. This finding may reflect on the existence of sub-reports on previous abortion, due to restrictive laws about abortion in Brazil like in most countries in Latin America, which makes them less likely to report previous abortions¹⁶.

The restrictive laws in relation to abortion in most developing countries lead women to use unsafe practices of abortion, competing for a larger occurrence of infections and genital trauma. In this study, the major complication related to abortion was infection, and these data are consistent with other studies that were investigated to severe maternal morbidity associated with abortion^9,12.

The frequency of complications was higher among women with gestational age above 12 weeks and this may reflect the delay in recognizing the pregnancy as well as, the difficulty to access health services. In contrast of this, other studies observed that complications were more frequent in early abortions^9,12.

One third of the women presented complications related to abortion, among which highlighted the need for surgical interventions and blood transfusion, septic shock and/or hypovolemic, sepsis and death. Even though these complications do not cause death, it can result in irreversible sequelae to medium and long term as the infertility and chronic pelvic pain, causing major impact on maternal health. Similar results were found in a systematic review on the incidence of severe maternal morbidity associated with abortion, which showed a higher incidence of serious complications when compared to deaths due to abortion¹⁷.

In addition to the individual and social damage, induced abortion complications have an impact on financial costs on the health sector, increasing the number of hospital admissions as well as inputs used for treatment of these complications¹⁸.

Although this study has limitations related to the use of secondary files, as well as the lack of classification of abortion, the findings have allowed to identify the main complications related to abortion in a tertiary hospital, reflecting on the regional reality.

CONCLUSION

Women with abortion complications were young, had good education level, living with a partner and were unemployed. The contribution of these complications in the maternal mortality rates is clear and we recommend the expansion of public health policies aiming to its reduction.