Objectives. To determine the frequency and profile of induced abortions among hospitalized cases of abortions in three tertiary hospitals in Egypt. Methods. A total of 517 consecutive cases of abortions with com- plete records were enrolled from three tertiary hospitals in Egypt: two hospitals in Cairo and one hospital in Alexandria. A data extraction sheet was designed to extract the required information from the records. It included: File No., Age, marital status, occu- pation, parity, number of children, previous abortion, history of contraception, trial of induction for this abortion and manage- ment of abortion in the hospital. The World Health Organization (WHO) criteria of categorizing the abortion as possible, probable or certainly induced abortion was used for classification of abor- tion cases. Results. The proportion of classified induced abortions (cer- tainly, probably and possibly induced abortions) was 30.6% in the total sample, being higher in Alexandria hospital (60.9%) compared to 14 and 19% in the other two hospitals respectively. Using the multiple logistic regression, the following factors were found independently related to induced abortions: Alexandria hospital (as proxy for residence), age ? 30 years and having more than 2 children. Conclusion. The current study revealed that about one third of hospitalized cases of abortion can be suspected of being induced. Induced abortion may be linked to elder age, higher number of children in the family and probably have geographical variation in Egypt

Habil, Ihab Shehad

Harb, H

PubMed

Journal of Preventive Medicine and Hygiene (JPMH)

J prev med hyg 2013; 54: 159-162159Objectives. To determine the frequency and profile of induced abortions among hospitalized cases of abortions in three tertiary hospitals in Egypt.Methods. A total of 517 consecutive cases of abortions with com-plete records were enrolled from three tertiary hospitals in Egypt: two hospitals in Cairo and one hospital in Alexandria. A data extraction sheet was designed to extract the required information from the records. It included: File No., Age, marital status, occu-pation, parity, number of children, previous abortion, history of contraception, trial of induction for this abortion and manage-ment of abortion in the hospital. The World Health Organization (WHO) criteria of categorizing the abortion as possible, probable or certainly induced abortion was used for classification of abor-tion cases.Results. The proportion of classified induced abortions (cer-tainly, probably and possibly induced abortions) was 30.6% in the total sample, being higher in Alexandria hospital (60.9%) compared to 14 and 19% in the other two hospitals respectively. Using the multiple logistic regression, the following factors were found independently related to induced abortions: Alexandria hospital (as proxy for residence), age ≥ 30 years and having more than 2 children.Conclusion. The current study revealed that about one third of hospitalized cases of abortion can be suspected of being induced. Induced abortion may be linked to elder age, higher number of children in the family and probably have geographical variation in Egypt.Original articleFrequency and profile of induced abortions:  hospital based study in tertiary hospitals in EgyptH. Harb, I. HabIl*Department of Obstetric & Gynecology, ain-Shams Faculty of Medicine; * Department of Community, Occupational and Environmental Medicine, ain-Shams Faculty of MedicineKey wordsInduced abortion • Tertiary hospitals • EgyptSummaryIntroductionThe conditions under which abortion is legally per-mitted are different in different countries  [1]. It is estimated that almost 40% of pregnancies over the world are unplanned  [2]. However, in Islamic coun-tries, this is completely forbidden except for medical reasons. Where induced abortion is illegal and largely inaccessible, little information is available on abor-tion practices outside the legal framework, putting women at the edge of unsafe abortion. Unsafe abor-tion refers to the termination of an unintended preg-nancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both  [3]. With such legal, ethical and religious considerations that hinder reporting, occur-rence tends to be under-reported in surveys, and unre-ported or under-reported in hospital records. Only the “tip of the iceberg” is, therefore, visible in the number of deaths and the number of women who suffer severe trauma, or who have an infection or severe blood loss and seek medical care [4].During rapid transition from high to low fertility, as has been witnessed in Egypt, contraceptive services are of-ten unable to meet the growing demand of couples for fertility regulation, resulting in an increased number of unplanned pregnancies, some of which are terminated by induced abortion. Also, where less effective family planning methods are commonly used, unplanned preg-nancies and, consequently, abortions are likely to oc-cur [4]. This puts additional sight to the importance of the issue of induced abortions nowadays.The aim of this study is to determine the frequency and profile of induced abortions among hospitalized cases of abortions in three tertiary hospitals in Egypt.Subjects and methodsThe current study was carried out in three tertiary hos-pitals in Egypt: one university hospital (A) and one spe-cialized tertiary hospital in Cairo (B); while the third hospital is a university hospital in Alexandria (C). The three hospitals were selected as they are the biggest ter-tiary and reference hospitals in the largest two cities in Egypt: Cairo and Alexandria.Sample sizeA sample size with 95% confidence interval was cal-culated to be at least 350 hospitalized subjects with abortion to detect proportion of induced abortions of 65%  ±  5% according to previous Egyptian study  [5]. The same sample size was able to detect a proportion of 35% ± 5% according to more recent published data in H. Harb, I. HabIl160Iran (a country with comparable demographic character-istics like Egypt) [6].The method of data collection was retrospective medical record review. A total of 517 consecutive cases of abor-tions with complete records were enrolled from the three selected hospitals. A data extraction sheet was designed to extract the required information from the records. It included: File No., Age, marital status, occupation, par-ity, number of children, previous abortion, history of contraception, trial of induction for this abortion and management of abortion in the hospital. When any of the required information was missing in the record, the record was not selected. All field investigators were se-lected with medical background (some doctors and some high institute nurses). They were trained on the extrac-tion sheet. Collected data were randomly re-checked by independent supervisors.Data from the medical records were extracted anony-mously and used only for the current research, The med-ical record number was used only for validation of data.The following World Health Organization criteria for distinguishing induced from spontaneous abortion were used [7]:•	 Certainly induced abortion: when the woman herself provides this information, or when such information is provided by a health worker or a relative (in the case of the woman dying), or when there is evidence of trauma or of a foreign body in the genital tract.•	 Probably induced abortion: when the woman has signs of abortion accompanied by sepsis or perito-nitis, and the woman states that the pregnancy was unplanned (she was either using contraception dur-ing the cycle of conception or she was not using contraception because of reasons other than desired pregnancy).•	 Possibly induced abortion: if only one of the “prob-ably” induced conditions listed above is present.•	 Spontaneous abortion: if none of the conditions list-ed above is present, or if the woman states that the pregnancy was planned and desired.Data analysisData were coded and analyzed using the SPSS program. Qualitative data were presented in frequency and per-centage while quantitative data were presented in mean and standard deviation. Logistic regression was used to identify independent factors related to induced abor-tions. Odds ratio and 95% confidence intervals were used to quantify the risk.ResultsA total of 517 abortion records were selected for this study from the three hospitals. Alexandria hospital (C) had cases with higher mean age and higher percentage of working women than the other 2 hospitals (Tab. I). As shown in Table II, the percentage of classified induced abortions (certainly, probably and possibly induced abortions) was 60.9% in C compared to 14% &19% in the other two hospitals respectively. No cases with cer-tainly induced abortion were reported in the A and B and 9 cases were classified as certainly induced abor-tions in C. Among the nine cases classified as certainly induced abortions, 4 of them were induced by a midwife and uncontrolled bleeding was the reason of hospitali-zation in seven cases. After hospital admission, 6 cases were diagnosed with incomplete abortion and 2 cases with threatened abortion and only one case with septic abortion (Tab.  III). Using the multiple logistic regres-sion, the following factors were found independently re-lated to induced abortions: Alexandria hospital (as proxy for residence), age ≥ 30 years and having more than 2 children (Tab. IV)DiscussionIt is estimated that million of pregnancies are voluntar-ily terminated each year, almost half of them outside the legal national system where the abortions are often per-formed by unskilled providers or in unhygienic condi-tions, or both [8].In studying induced & unsafe abortions, especially in a country like Egypt where such practice is illegal, it is expected that patients will deny induced abortions. Thus, the health care facility is the most logical, cost-effective and convenient place to conduct the research where women with complications are treated. For this reason, the majority of abortion studies have been hospi-tal-based and it is likely that most future studies will be conducted in hospitals as well [9].The current study showed that the personal characteris-tics of abortions admitted in hospitals differs from one area to another. In Table I, abortion cases in Alexandria Tab. I. Characteristics of the study group.University Hospital in Cairo (A)Tertiary Hospital in Cairo (B)University Hospital in Alexandria (C)TotalNo. enrolled 151 205 161 517Age (m ± Sd) 27.6 ± 6.5 27.55 ± 6.3 29.5 ± 5.6* 28.18 ± 6.2Working women [No.(%)] 8 (5.3) 9 (4.4) 60 (37.3)** 77 (14.9)No. Children [No. (%)] 0 58 (38.4) 66 (32.2) 4 (2.5) 128 (24.8)1-2 62 (41.1) 90 (43.9) 96 (59.6) 248 (48)≥ 3 31 (20.5) 49 (23.9) 61 (37.9) 141 (27.3)* p < 0.05 vs. hospital A & B; ** p < 0.001.Frequency and proFile oF induced abortions161hospital had higher mean age and higher prevalence of working women.In most of Islamic countries as well in other counties, where induced abortions are illegal, such induced abor-tions are often under-reported. The WHO classification of abortion was developed to overcome such problem and was used in this study to classify abortions whether induced or not [7]. The present study revealed that clas-sified induced abortions (certainly, probable and pos-sible induced abortions) accounted for almost 30% of the studied cases (Tab. II). A former study, carried out in Egypt many years ago, reported higher prevalence of almost 65%  [5]. However, the current study was car-ried out in tertiary hospitals in the biggest two cities: Cairo and Alexandria in contrast with the former study that took a sample of public hospitals across the differ-ent cities. A study carried out in Iran, a country with comparable cultural and religious background to Egypt, revealed that 12% of hospitalized abortions reported that they were illegally induced although about 35% of these pregnancies were not planned which may infer that such abortions percentage is underestimated [6]. Earlier stud-ies showed percentage of induced abortions among all hospitalized abortions ranging from 15% [10] to more than 50% [11] which points to wide variation among dif-ferent countries.Table III showed that among the certainly induced re-ported abortions, 4 cases (44%) were carried out by a midwife. In Pakistan, midwifes also were responsible for 43.8% of induced abortions [12]. In contrast, most cases of induced abortion in Latin America are medi-cation induced [13, 14]. This may be evidently linked to difference in culture and sexual behavior that pose women in some countries like Brazil to earlier and repeated experience. Bleeding was the main cause of hospitalization of certainly induced abortions and all of the 9 cases categorized as certainly induced abortions were given hospital diagnosis other than induced abor-tion (Tab. III).The current study showed that elder age (≥  30  ys), having more than 2 children, and Alexandria hospital (C) were independent predictors of induced abortions (Tab. IV). Huntington and his colleagues, in their previ-ous study in Egypt concluded a similar finding regard-ing age relation to the induced abortions where induced abortions had higher mean age than cases with spontane-ous abortions [8]. Other studies reported younger age as a risk factor for induced abortions [13] but this may be interpreted by the difference in sexual behavior in the different countries. In some countries where sexual be-havior before marriage at younger age is common, un-wanted pregnancies may be common and hence induced abortions may be prominent at younger age. In contrast, where sexual behavior before marriage is not common, as in our country, unwanted pregnancies may be linked to failure or underutilization of contraceptive methods which occur later in the marriage history.As shown in Table IV, number of children (more than 2) was identified as an independent risk factor for induced abortion. Higher number of children can be regarded as determinant of unwanted future pregnancy that in turn is linked to induced abortion. In Egypt, More than half of women in reproductive age group want to limit their fam-ily size to only two children [15]. This agrees with many studies that observed higher risk of induced abortions in presence of more children in the family [12, 16, 17].The current study revealed an interesting finding, where classified induced abortions were significantly more frequent in Hospital C than the other two hospitals. All three hospitals have the same scope and level of health-care service. Yet, Hospital C is located in different city with probably different referred population. Thus, Hos-pital C was regarded as proxy for the residence. Induced abortions have shown relation to geographic variation within the same country [18, 19]. This can be explained by socio-cultural disparities within same country that have impact on sexual practices as well perception of fertility.The current study highlighted the potential burden of induced abortion; a masked health problem in our country; and its possible determinants. The study iden-tified some predictable determinants like elder age and Tab. II. Frequency of induced abortions in the studied hospitals.University Hospital in Cairo (A)No. (%)Tertiary Hospital in Cairo (B)No. (%)University Hospital in Alexandria (C) No. (%)TotalNo. (%)Certainly induced 0 (0) 0 (0) 9 (5.6) 9 (1.7)probably induced 0 (0) 1 (0.5) 2 (1.2) 3 (0.6)possibly induced  21 (13.9) 38 (18.5) 87 (54) 146 (28.2)Spontaneous abortion 130 (86.1) 166 (81) 63 (39.1) 359 (69.4)Tab. III. profile of the reported (certainly) induced abortions.No. (%)n = 9method usedSelf induced with medication 1 (11.1)Self induced with unspecified method 4 (44.4)midwife 4 (44.4)reason of hospitalizationBleeding 7 (77.8)Non-specific 2 (22.2)hospital diagnosisThreatened abortion 2 (22.2)Incomplete abortion 6 (66.7)Septic abortion 1 (11.1)hospital managementd&C/ suction &evacuation 7 (77.8)medical management 2 (22.2)H. Harb, I. HabIl162high number of children in the family, yet it pointed a possible importance of geographical variation of such practice within Egypt. This would call for researches that study such geographical distribution of induced abortions.Limitation of the studyThis study was conducted on cases of abortion admitted to tertiary hospitals and the method of collection of data was record review. Data extracted from record review are limited to those provided in the record. Accordingly important potential risk factors like education, income and other social factors were missed from such study as they were not included in the medical record. Study of induced abortion in a country like Egypt represents a challenge as subjects will often deny such practice, mak-ing interviewing of subjects difficult and threaten valid-ity and reliability of the tool.References[1] Belsey M. World Health Organization studies differentiating between spontaneous and induced abortions. In: Coeytaux F, et  al., eds. Methodological issues in abortion research. New York: The Population Council 1989.[2] The Alan Guttmacher Institute (AGI). Sharing Responsibility: Women, Society and Abortion Worldwide. New York: AGI 1999.[3] World Health Organization. The prevention and management of unsafe abortion. Report of a Technical Working Group. Ge-neva. World Health Organization 1992 (WHO/MSM/92.5).[4] World Health Organization. Unsafe abortion: global and re-gional estimates of incidence of unsafe abortion and associated mortality in 2003. 5th ed, 2007.[5] Huntington D, Nawar L, Hassan E, et  al. The Postabortion Caseload in Egyptian Hospitals: A Descriptive Study. Trop Heal. 1992;11:13-6.[6] Majlessi F, Forooshani AR, Shariat M. Prevalence of induced abortion and associated complications in women attending hos-pitals in Isfahan. East Mediterr Health J 2008;14:103-9.[7] World Health Organization. Protocol for hospital-based de-scriptive studies of mortality, morbidity related to induced abortion, WHO Project No. 86912, Task Force on Safety and Efficacy of Fertility Regulating Methods. WHO, Geneva, re-vised edition of Aug. 14, 1987.[8] Sedgh G, Henshaw S, Singh S, et al. Induced abortion: estimat-ed rates and trends worldwide. Lancet 2007;13;370:1338-45.[9] World Health organization. Studying unsafe abortion: a practi-cal guide. WHO/RHT/MSM/96.25. 1996[10] Lema VM, Rogo KO, Kamau RK. Induced abortion in Kenya: its determinants and associated factors. East Afr Med J 1996;73:164-8.[11] Abdella A. Demographic characteristics, socioeconomic pro-file and contraceptive behaviour in patients with abortion at Jimma Hospital, Ethiopia. East Afr Med J 1996 Oct;73:660-4.[12] Korejo R, Noorani KJ, Bhutta S. Sociocultural determinants of induced abortion. J Coll Physicians Surg Pak 2003;13:260-2.[13] Misago C, Fonseca W, Correia L, et al. Determinants of abor-tion among women admitted to hospitals in Fortaleza, North Eastern Brazil. Int J Epidemiol 1998; 27:833-9.[14] Kulczycki A. Abortion in Latin America: changes in practice, growing conflict, and recent policy developments. Stud Fam Plann 2011; 42:199-220.[15] El-Zanaty, Fatma and Ann Way. 2009. Egypt Demographic and Health Survey 2008. Cairo, Egypt: Ministry of Health, El-Zanaty and Associates, and Macro International.[16] Hansen MH, Mølgaard-Nielsen D, Knudsen LB, et al. Rates of induced abortion in Denmark according to age, previ-ous births, and previous abortions. Demographic Research 2009;21:647-80.[17] Acharya R. Estimating parity specific rate of induced abor-tion: A new approach. Paper presented at the XXIV General Population Conference of the International Union for the Scien-tific Study of Population (IUSSP) during 18-24 August 2001 at Salvador, Bahia, Brazil. http://www.iussp.org/Brazil2001/s20/S21_01_Acharya.pdf. Accessed July 29th, 2012.[18] Uthman OA. Geographical variations and contextual effects on age of initiation of sexual intercourse among women in Nige-ria: a multilevel and spatial analysis. Int J Health Geograph 2008;7:27.[19] Geelhoed DW, Nayembil D, Asare K, et  al. Contraception and induced abortion in rural Ghana. Trop Med Int Health 2002;7:708-16.Tab. IV. Factors related to induced abortions.Induced abortionsNo. (%)Spontaneous abortionsNo. (%)OR (95% CI)*HospitalA 21 (13.3) 130 (36.2) 1B 39 (24.7) 166 (46.2) 1.5 (0.8-2.9)C 98 (62) 63 (17.5) 11.1 (5.8-21)Working women 27 (17.1) 50 (13.9) 1.3 (0.8-2.1)Age ≥30 92 (60.1) 108 (30.9) 2.3 (1.4-3.7)No. children > 2 85 (53.8) 56 (15.6) 4.6 (2.8 7.7)* Using logistic regression.n Received on January 2, 2013. Accepted on June 5, 2013n Correspondence: Ihab Shehad Habil, Department of Community, Occupational and Environmental Medicine, Faculty of Medicine, Ain-Shams University, Abbassia Square, Cairo, Egypt - Tel. 0020-2-24837888 - E-mail: ishehad@yahoo.com

Frequency and profile of induced abortions:hospital based study in tertiary hospitals in Egypt

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Frequency and profile of induced abortions:hospital based study in tertiary hospitals in Egypt

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