Incidence and Complications of Unsafe Abortion in Kenya
Unsafe abortion is defined by the World Health Organization (WHO) as a procedure for terminating pregnancy, carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. Under the 2010 Kenyan constitution, abortion may be granted to a pregnant woman or girl, when in the opinion of a trained health professional, she needs emergency treatment or her life or health is in danger. Nevertheless, unsafe abortion remains a leading cause of maternal morbidity and mortality in Kenya. The treatment of complications of unsafe abortion also consumes significant health systems resources. In this report, we document findings from a recent nationwide study of the incidence of induced abortion and severity of complications of unsafe abortion in Kenya. The study was conducted in 2012 among a nationally-representative sample of Levels II to VI public and private health facilities. The Abortion Incidence Complications Methodology (AICM) and the Prospective Morbidity Methodology (PMM) were used as well-established and complementary approaches to estimate abortion incidence and the severity of unsafe abortion complications in Kenya.
Our analysis indicates that an estimated 464,690 induced abortions occurred in Kenya in 2012, corresponding to an induced abortion rate of 48 abortions per 1000 women of reproductive age (15-49 years), and an induced abortion ratio of 30 abortions per 100 births in 2012. We also estimate that 157,762 women received care for complications of induced and spontaneous abortions in health facilities in the same year. Of these, 119,912 were experiencing complications of induced abortions. Based on patient-specific data, women who sought abortion-related care were socially, demographically and economically heterogeneous. They included educated and uneducated women, urban and rural women, Christians, Muslims, and women of ‘other faiths’; students, unemployed and employed women as well as married, never-married and divorced women. Based on the severity classification, about 23% of the women who presented for post-abortion care (PAC) presented with mild complications, 40% with moderately severe and 37% with severe complications (such as high fever, sepsis, shock, or organ failure). Severe complications of unsafe abortions were most common among women aged 10-19 (45%), divorced women (56%), and women who reported to the provider that they had interfered with the continuation of the pregnancy (58%). More than 70% of women seeking postabortion care were not using a method of contraception prior to becoming pregnant. Similarly the results of the 2008/09 Kenya Demographic and Health Survey found that 43% of births in the preceding five years were reported by women as unwanted or mistimed. Both of these findings illustrate that there are still significant barriers to access and use of effective contraceptive methods in Kenya.
No clinical procedure was performed in 28% of PAC cases. Among women who had a uterine evacuation procedure performed, manual vacuum aspiration (MVA) and electrical vacuum aspiration (EVA) were used to manage 65% of the cases. Digital evacuation, dilation and curettage (D&C) and medical abortion were other common Incidence and Complications of Unsafe Abortion in Kenya 8 procedures used to manage PAC cases. A relatively high case-fatality rate was calculated; it is estimated that 266 Kenyan women die per 100,000 unsafe abortions. Compared to other countries in East Africa where similar data have been gathered, Kenya’s rates of induced abortion, proportion of abortion complications categorized as severe, and the abortion complication fatality rate remain disproportionately high. There is also evidence that while the use of MVA/EVA and medical abortion is growing in Kenya, other less safe procedures such as D&C and digital evacuation remain widespread, suggesting critical inequities in Kenya in the availability of basic essentials for high quality PAC and safe induced abortion.
The effective implementation of the constitution in Kenya has the potential to promote women’s access to safe abortion services and support reductions in complications of unsafe abortion. An urgent need also exists for the training of providers to offer safe services and for the wider implementation of the abortion care-related Standards and Guidelines of the Ministry of Health. In addition, it will be essential that concerted efforts are made to urgently reach women who have unmet contraceptive needs, support women’s access to post-abortion contraceptive counseling and methods, and promote access to quality abortion-related care within the limits of the Kenyan law and the constitution.