Full text of DOI:10.1016/S0968-8080(02)00024-1

Ó 2002 Reproductive Health Matters. Published by Elsevier Science. All rights reserved.
Reproductive Health Matters 2002;10(19):18–21
0968-8080/02 $ – see front matter
PII: S0968-8080(02)00024-1
www.elsevier.com/locate/rhm
Complications of Unsafe Abortion: A Case Study
and the Need for Abortion Law Reform in Nigeria
Boniface A Oye-Adeniran, Augustine V Umoh, Steve NN Nnatu
Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Lagos, Nigeria.
E-mail: oye@beta.linkserve.com, bonifaceoye@yahoo.com
Abstract Complications of unsafe abortion account for 30–40% of maternal deaths in Nigeria. This paper reports a
case of unsafe abortion by dilatation and curettage, carried out by a medical practitioner in a private clinic on a 20-
year-old single girl in Lagos, Nigeria. The girl was 16 weeks pregnant. She suffered complications consisting of per-
foration of the vaginal wall through the utero-vesical space into the abdominal cavity with gangrenous loops of
small intestine herniating through it. Information was obtained from her case notes and the operating theatre reg-
ister. She had a resection and anastomosis of the small intestine and had to remain in hospital, where she made a
full recovery, for two weeks. Unsafe abortion is fraught with many complications, including pelvic sepsis, septi-
caemia, haemorrhage, renal failure, uterine perforation and other genital tract injuries, and gastro-intestinal tract
injuries. Where expert, emergency treatment for these is not available, women die. Unsafe abortion procedures, un-
trained abortion service providers, restrictive laws and high morbidity and mortality from abortion tend to occur to-
gether. We advocate for a review of the existing restrictive laws in Nigeria in order to reduce the high morbidity and
mortality from unsafe abortion. Ó 2002 Reproductive Health Matters. Published by Elsevier Science. All rights re-
served.
Keywords: clandestine and unsafe abortion; maternal mortality and morbidity; abortion service providers; Nigeria
S many as 53 million pregnancies are esti-
mated to be terminated by induced abortion
each year worldwide [2], while in Nigeria
law. In fact, many abortions are performed by un-
skilled abortion care providers, as the following
case reported shows.
A
an estimated 610,000 abortions are performed
yearly [3]. A significant number of these abortions
are thought to be performed by physicians in Nige-
ria and are generally assumed to be relatively safe
[3,4]. However, unsafe abortions remain a major re-
productive health concern in Nigeria and indeed in
most other parts of the developing world [3]. They
are also a major contributor to maternal mortality,
accounting for as many as 30–40% of maternal
deaths in Nigeria and one in eight maternal deaths
in the West African sub-region as a whole [3–5].
Abortion is legal only when done to save the life
of a woman in Nigeria, which is restrictive by
Case report
A 20-year-old, single girl with no children was
admitted to the accident and emergency department
of Lagos University Teaching Hospital in January
2000 with a nine-hour history of protrusion of a
mass from the vagina. The information reported
here was obtained from her case notes and the op-
erating theatre register.
Earlier that day she had had an attempted termi-
nation of a 16-week pregnancy by dilatation and
curettage (D&C) at a private hospital. However, she
18

BA Oye-Adeniran et al. / Reproductive Health Matters 2002;10(19):18–21
Figure 1. Loops of gangrenous small intestine protruding from the vagina, 20-year-old girl, Lagos University
Teaching Hospital, Nigeria.
became restless with the injection of an anaesthetic
drug (ketamine), and an attempt at the passage of
instruments into the vagina for the procedure led
to a suspected uterine perforation. The procedure
was subsequently abandoned and the patient was
referred to our Gynaecological Emergency Centre.
The patient, however, went home instead because
of the fear of coming to a public institution.
At home, while eating, she developed a cough
and with each coughing episode she noticed an
increasing protrusion of a mass from her vagina.
She was brought to the Gynaecological Emergency
Centre with associated abdominal pain and mild
bleeding from the vagina as well. She said she
had had an induced abortion (at six weeks of preg-
nancy) the previous year without complications.
On examination, she was found to be mildly de-
hydrated and pale but with a normal pulse rate of
84 beats/min and blood pressure of 120/70 mmHg.
Her abdomen was not distended, the Fundal height
was 16-week size and the bowel sounds were ab-
sent. There were loops of gangrenous small in-
testine protruding from her vagina (Figure 1). A
diagnosis of uterine perforation with herniation of
the small intestine was made. She was resuscitated
with intravenous fluids and antibiotics, and had
an emergency exploratory laparotomy.
At surgery, a perforation through the utero-vesi-
cal space was found with herniation of the small
intestine through it. The uterus was still intact and
no injury was seen. The gangrenous small bowel
was reduced, i.e. returned to the abdominal cavity
through the perforation, and a resection and anasto-
mosis (excision and rejoining) was performed. The
perforation in the utero-vesical space was repaired.
While awaiting proper second trimester induction,
the patient expelled the products of conception
spontaneously three days post-operatively and an
evacuation by manual vacuum aspiration was done.
She was maintained on appropriate antibiotics,
made a satisfactory recovery and was discharged
two weeks post-admission. She was also given con-
traceptive counselling and referred to the Depart-
mental Family Planning Clinic for services.
19

BA Oye-Adeniran et al. / Reproductive Health Matters 2002;10(19):18–21
Comment
Unsafe abortion is fraught with many complica-
The issue of abortion remains a delicate one in
our country, presenting a complex moral and ethi-
cal dilemma. In all societies, however, no matter
what the legal, moral or cultural status of abortion
is, there are women who will seek to terminate an
unwanted pregnancy [10]. While correct and con-
sistent use of highly effective contraception will
prevent most unwanted pregnancies and greatly re-
duce the need for abortion, it cannot eliminate this
need [11,12], nor have most Nigerian women and
men yet achieved this level of contraceptive use
[13].
It is for reasons such as these and in order to pre-
vent the serious morbidity reported here, which is
so costly for women’s health and for the health ser-
vice itself, that many have advocated the need for
reform of the current abortion law and policy, to
ensure that safe abortion services are made avail-
able to all women in need, as well as training for
abortion service providers [11,14]. Unsafe abortion
procedures, untrained abortion service providers,
restrictive laws and high morbidity and mortality
from abortion tend to occur together [14]. It is
therefore necessary to advocate for a review of
the existing restrictive laws in Nigeria in order to
reduce the high morbidity and mortality from un-
safe abortion.
tions, including pelvic sepsis, septicaemia, haemor-
rhage, renal failure, uterine perforation and other
genital tract injuries, gastro-intestinal tract injuries.
Where emergency expert treatment for these is not
available, death will result [6,7]. This case of induced
abortion with bowel injury highlights the persisting
problems of unsafe abortions in Nigeria. Bowel in-
jury is a serious and life-threatening complication
in a case such as this [6], though occurring in this girl
in an unusual presentation. Complications such as
this occur when abortion is badly performed, partic-
ularly by untrained personnel and in unhygienic
conditions [7]. While a significant and increasing
number of abortions are being performed by physi-
cians, usually in private clinics and hospitals
[2,8,9], these abortions must be done in secretive
conditions and training for the doctors involved is
often less than optimal or non-existent. This happens
when the law is so restrictive, as is the case in Nige-
ria. This situation is exemplified by this case report,
in which the provider attempted a second trimester
termination using D & C, failed to take the patient di-
rectly to the referral centre or at least arrange for her
immediate transfer, and then the patient was too
frightened to come to a public hospital on referral.
References
1. Medical methods of termination of
starting a movement. Afr J Reprod
Health 1999;3(2):7–10.
6. Megafu U. Bowel injury in septic
abortion: the need for a more aggres-
sive approach. Int J Gynecol Obstetrics
1980;450–453.
7. Aimakhu VE. Abortions. Tropic J
Obstetrics Gynaecol 1995;12(Suppl 1):
72–6.
8. Makinwa-Adebusoye P, Singh S, Au-
dam S. Nigerian health professionals’
perceptions about abortion practice.
Int Family Plan Perspect
Ababa, Ethiopia. East Afr Med J
2001;78(1):25–9.
pregnancy – A report of a WHO
Scientific Group. World Health Orga-
nization Technical Report Series.
Geneva: WHO; 1997.
2. Henshaw SK, Singh S, Oye-Adeniran
BA, et al. The incidence of induced
abortion in Nigeria. Int Family Plan
Perspect 1998;24(4):156–64.
3. Adewole IF. Trends in postabortal
mortality and morbidity in Ibadan,
Nigeria. Int J Gynecol Obstetrics
1992;38(2):115–8.
4. Okonofua FE, Odimegwu E, Ajabor H,
et al. Assessing the prevalence and
determinants of unwanted pregnancy
and induced abortion in Nigeria. Stud
Family Plan 1999;30(1):67–77.
5. Whitaker C, Germain A. Safe abortion
in Africa: ending the silence and
11. Singh K, Ratnam SS. The influ-
ence of abortion legislation on mater-
nal mortality. Int J Gynecol
Obstetrics 1998;63(Suppl 1):
S123–9.
12. Maine D, Karkazis K, Bolan N. The bad
old days are still here: abortion mor-
tality in developing countries. J Am
Med Women’s Assoc 1994;49(5):
137–42.
13. Otolorin EO. Reproductive health in
Nigeria: an overview. Dokita Sympo-
sium Proceedings, June 1997. p.
1–9.
14. Berer M. Making abortions safe: a
matter of good public health policy
and practice. Bull World Health Orga-
nization 2000;78(5):580–92.
1997;23(4):155–61.
9. Thapa S, Padhye SM. Induced abor-
tion in urban Nepal. Int Family
Plan Perspect 2001;27(3):
144–7.
10. Tadesse E, Yoseph S, Gossa a Muletta
E, et al. Illegal abortions in Addis
20

BA Oye-Adeniran et al. / Reproductive Health Matters 2002;10(19):18–21
´
´
Resume
Les complications consecutives a un avortement
ꢀ ꢁ
Resumen
ꢀ
ꢁ
Entre el 30 y el 40 por ciento de las muertes
maternas en Nigeria se deben a complicaciones de
abortos practicados en condiciones de riesgo. Este
ꢁ
ꢀ
a risque representent 30–40% des deces maternels
au Nigeria. Cet article decrit un avortement par di-
ꢀ
ꢀ
ꢀ
ꢀ
ꢀ
artıculo describe el caso de una joven soltera de
latation et curetage mene par un praticien medical
ꢀ
ꢀ
~ ꢀ
20 anos con 16 semanas de embarazo a quien un
dans une clinique privee sur une celibataire de
ꢁ
ꢀ
ꢀ
ꢀ ꢀ
medico en una clınica privada en Lagos, Nigeria
20 ans a Lagos, Nigeria. La patiente etait enceinte
ꢀ
le hizo un aborto por dilatacion y curetaje. Ella su-
de 16 semaines. Elle souffrait d’une perforation de
ꢀ
ꢀ
ꢀ ꢀ
frio como complicaciones la perforacion de la
la paroi vaginale par l’espace utero-vesical dans
ꢀ
ꢀ
ꢀ
lacavite abdominale, des anses gangrenees de l’in-
pared vaginal atravesando el espacio utero-vesical
^
testin grele formant des hernies. Les informations
ꢀ ꢀ
hasta la cavidad abdominal con lazos del intestino
delgado gangrenosos enclavados en ella. Se obtuvo
ꢁ
ont ete obtenues a partir de son dossier et du regis-
ꢀ
ꢀ
ꢀ ꢀ
la informacion de su ficha medica y del registro del
tre de la salle d’operation. Elle a subi une resection
^ ^
^
ꢀ
ꢀ
et une anastomose de l’intestin grele et a du etre
hospitalisee pendant deux semaines avant de se re-
quirofano. Le hicieron una reseccion y anastomosis
del intestino delgado, y ella tuvo que permanecer
ꢀ
ꢀ
ꢁ
ꢀ
ꢀ
ꢀ
tablir completement. L’avortement non medicalise
hospitalizada por dos semanas, recuperandose com-
comporte beaucoup de complications: infection
pletamente. El aborto practicado en condiciones de
ꢀ
ꢀ
ꢀ
ꢀ
riesgo conlleva muchas complicaciones, incluıdas
pelvienne, septicemie, hemorragie, insuffisance re-
ꢀ
ꢀ
ꢀ
la sepsis pelvica, septicemia, hemorragia, paro re-
nale, perforation uterine et autres lesions de l’appa-
ꢀ
ꢀ
ꢀ ꢀ ~
nal, perforacion del utero y otros danos al aparato
reil genital, et lesions de l’appareil gastro-intestinal.
ꢀ
ꢀ
~
Quand un traitement specialise d’urgence n’est pas
genital, y danos al aparato gastrointestinal. Donde
ꢀ
ꢁ
disponible, les femmes meurent. Les procedures a
no existan tratamientos de urgencia especializa-
dos para estas condiciones, las mujeres mueren.
Suelen conjugarse las intervenciones malhechas,
los proveedores no calificados, las leyes restricti-
vas y la alta morbi-mortalidad a causa del aborto.
ꢀ
risque, les praticiens non formes et les lois restricti-
ꢁ
€
ꢀ
ꢀ
ves tendent a coıncider avec des taux eleves de
ꢀ
ꢀ
ꢁ
morbidite et de moralitedues a l’avortement. Nous
plaidons pour une revision des lois restrictives en
ꢀ
ꢀ
ꢀ
ꢀ
ꢀ
ꢀ
vigueur au Nigeria afin de re duire les taux eleve
Estamos a favor de una revision de las leyes restric-
ꢀ
ꢀ
de morbidite et de mortalite dues aux avortements
tivas en Nigeria para reducir la alta morbi-mortali-
dad del aborto inseguro.
ꢁ
a risque.
21