The diversity of abortion methods

Women have always turned to abortion to regulate their fertility, using a whole variety of methods and passing the knowledge of these down from generation to generation (McLaren A., 1990).The methods of abortion available largely depend on the legal status of the act. However even where abortion is partially or totally illegal, there is always a supply, whether this is based on medical practices or local methods. The risks, costs and consequences of these abortions are linked to the method chosen. This choice of method depends on the technology available in the country concerned and on the term of the pregnancy. It may be guided by a medical or informal provider, by friends or by the woman's immediate circle.

A diverse range of methods

A whole range of abortive or supposedly abortive procedures is known to women, even if the efficiency of these procedures has no scientific basis or proof. In order to interrupt a pregnancy, women use the services of traditional practitioners, medical staff and unqualified providers, and even attempt to act by themselves. In the study conducted by The Alan Guttmacher Institute (1999), traditional methods of abortion can be divided into six groups as follows: natural or herbal methods, manufactured methods, "physical" methods, voluntary trauma, pharmaceutical products and prayers and gris-gris (see table).

In traditional pharmacopoeia, plants are renowned for their contraceptive and abortive properties. These methods are sometimes described in literature on the subject as ways to "bring on a period" rather than to abort. They can be purchased at markets or prescribed by traditional practitioners. They are taken in the form of drinkable solutions, enemas or vegetal pessaries. They can cause infections, haemorrhages, comas, fever and even the death of the woman concerned. In the north of Burkina Faso, women drink an herbal tea that provokes uterine contractions and abortion, however the side effects, severe haemorrhaging in particular, are serious (Dehne K.L, 1999).

In addition to these methods there are all kinds of products which, although not actually abortive in themselves, leave serious aftereffects - for example manufactured chemical products such as detergent, gasoline, bleach etc., acidic or alcoholic products such as wine, vinegar, white alcohol, lemon juice etc.), and also sugary products such as coca-cola etc.

Certain pharmaceutical products are also renowned for their abortive properties. These are essentially drugs that are not recommended for pregnant women and taken in overdose, for example antimalarial medication such as Nivaquine and quinine, hormones such as Crinex and Synergon, aspirin and Paracetamol, antibiotics and so on. Sometimes several of these products are combined for greater "efficiency". Cytotec, which is frequently used as an abortive product in Latin America and the Caribbean, is rarely used in Africa. Quinine, when used in very high doses, has grave consequences on women's health, even when it does not produce the abortion anticipated (Smit J. A. and McFadyen, M. L., 1998). In Ethiopia, Getahun H. and Berhane Y. (2000) have noted that anti-malarial medication, along with the insertion of objects into the vagina, are the two principal methods of abortion.

Physical methods consist essentially of inserting objects into the vagina, such as plant stems or roots, blunt objects, ground glass, metal or plastic objects such as bicycle spokes or catheters, and so on. These techniques frequently cause perforation of the uterus and haemorrhaging, and even the death of the woman concerned. Other techniques include massaging or manipulation of the uterus, violent physical exertions, blows, falls and finally, in an entirely different approach, prayers, gris-gris and amulets, which are certainly less dangerous for women's health.

Abortions are also conducted using medicalized methods that vary according to the term of pregnancy. In Africa the method principally used is a surgical one, curettage, which is most often practised under general anaesthetic. This can cause infections, haemorrhaging and other aftereffects that may put further pregnancies at risk. The vacuum aspiration method is very often used where abortion is authorized. This method is less traumatic than curettage and is practised under local or sometimes general anaesthetic at up to 12 weeks of pregnancy. There are rarely any complications with this method. Vacuum aspiration is increasingly used to treat post-abortion complications, and health programmes have introduced it into many African hospitals (see below). These medicalized methods necessarily involve the intervention of medical staff and generally provide women with some security. However, in countries where abortion is practised illegally, in medically inappropriate environments and by unqualified or insufficiently qualified personnel, the risks are manifold. Wearing a white coat can be enough to make an unqualified person appear sufficiently competent to carry out this kind of procedure. Some abortions are carried out in private hospitals or clinics, but others are conducted in "informal health structures", or simply at home with neither security nor hygiene.

Illegally provided medicalized abortions

The analysis of abortion practices in different countries reveals a diverse range of approaches and methods.

Thus in Cameroon, Calves A.E. (2002) found that although most illegal abortions are carried out by doctors or nurses, a not inconsiderable proportion are conducted by non-medical individuals using unsafe methods. In a study conducted in Tanzania on women admitted to health centres for abortion-related complications, Mpangile S and al. (1993) detail the profiles of 384 people who have carried out these abortions - 22% were doctors, or were identified as such, 65% were other medical staff and 13% were traditional practitioners. Whilst 56% of abortions are carried out in a medical environment, 42% take place in a normal room. In Nigeria, teenagers most frequently seek the services of a midwife, a pharmacist or a friend to abort, in order to minimise costs (Ejiro Emuveyan E., 1994).

In Egypt, Lane and al. (1998) highlight a whole range of abortion methods which differ according to their safety and cost, the two being closely linked. Women may use traditional methods just as much as medicalized abortions conducted in illegal clinics or practised by gynaecologists. In Gabon, women use medicalized methods for the most part, such as dilatation and curettage (40%), vacuum aspiration (2%), catheter (6%) and injections (12%). These methods, which are considered modern, can encompass archaic procedures such as the use of knitting needles and cassava stalks etc. 16% of women claim to have used pharmaceutical products as much as herbal treatments. Teenagers, on the other hand, use medicalized methods such as curettage and vacuum aspiration less than older women (Barrère M, 2001). Whilst 35% of these procedures are conducted by doctors and 7% by other medical personnel, 27% are carried out by people outside the medical field, and in a third of cases the woman acts by herself.  In almost half of all cases, these abortions take place in public or private health establishments, 48% are carried out at the woman's home and 2% at the home of the person practising the abortion.

In Bamako, over two thirds of abortions of all method types are carried out in hospitals, and 27% at home. In 88% of cases the procedure is conducted by medical personnel, in 8% by traditional healers and in 2% of cases by the woman herself (Konate M.K. and al., 1996). Over two thirds of these abortions are conducted using medicalized methods, mainly curettage, whilst 13% are conducted by the insertion of an object, 10% using pharmaceutical products and 9% with herbal treatments.

In Abidjan, 62% of women who wished to interrupt their pregnancies used a medicalized method, 10% used "medication", 18% enemas and 9% vegetal catheters (Guillaume A. and Desgrées du Loû A., 2002). In urban areas of Togo, 71% of women have had an abortion using a medicalized method. Medication taken orally and traditional methods are each used by 13% of women, and 9% use injections (Unité de Recherche Démographique and al., 2001). In these countries, medicalized methods are used more frequently in urban areas, where "abortion services" are more widely provided, than in rural areas.

Abortions by curettage are sometimes used following failed attempts using other methods. Traditional or local methods do not always work and sometimes simply induce the beginnings of an abortion, necessitating the treatment of the consequences in a medical structure. In Togo, 13% of women have tried to abort using other methods before turning to medical treatment. A large number of them go to hospital in order to treat complications that have arisen from such abortion attempts (Unité de Recherche Démographique and al.,2001).

The risks associated with abortion vary according to the type of method used. In fact the methods cited by women who have suffered post-abortion complications are markedly different from those mentioned by women who have had no complications. Whilst medicalized abortion does not entirely exclude the risk of complications, such complications are generally less serious and there is a less frequent need for hospitalization.

Thus Likwa R.N. (1993) demonstrates, based on a study conducted in four East African countries, that most women who have died following abortion-related complications carried out their abortions themselves using traditional products. In Ethiopia, a study on these complications conducted in five gynaecological and obstetrics departments in Addis Ababa, shows that in a third of cases such abortions were induced by an overdose of antibiotics (Ampicillin), 46% were induced by the insertion of plastic tubes or catheters, and 22% by the insertion of metal catheter. The procedure was either carried out by the woman herself (in 28% of cases), by a health worker (35%), and in almost a quarter of cases by non-medical individuals (Tadesse E. and al., 2001; Kebede, S. and al., 2000).

Several studies on abortion-related complications conducted in Nigeria show that the abortions concerned were for the most part carried out by non-medical individuals or medical staff not qualified for this kind of procedure, such as nurses, pharmacists and general practitioners, and that the procedure itself often took place in a non-medical environment in unhygienic conditions (Adewole I.F., 1992; Henshaw S. and al.,1998; Anate M. and al., 1995).

In three West African hospitals (in Benin, Senegal and Cameroon), a study indicates that complications following induced abortions are due to self-induced abortions in 40% of cases, to abortions performed with the help of medical staff in 51% of cases, and in the remainder of cases to abortions performed with the help of traditional practitioners (Goyaux N. and al., 2001). In Abidjan, Goyaux N. and al., (1999) noted that women admitted to hospital for such complications had tried to abort by inserting plant stems into the vagina (31%), by using vegetal pessaries (23%) or herbal infusions (20%). In Benin, Alihonou E. and al. (1996) show that more than half of women have had complications following abortions that they induced themselves by overdosing on pharmaceutical products. In Mauritius, the majority of women hospitalized for abortion-related complications had induced the abortion themselves using herbal treatments, by inserting objects into the vagina or by taking misoprostol (Anonymous, 1993).

Two studies conducted in Zambia highlight the risks to which women expose themselves through abortion methods. Likwa RN (1994) describes how, in one third of cases, women use intra-uterine methods such as inserting cassava roots, whilst Castle MA (1990) shows that very young women sometimes drink petrol or detergent-based mixtures, or take overdoses of medication such as chloroquine or aspirin, or other toxic substances.

A new medicalized method

Health programmes are being implemented in various developing countries to introduce medication-induced abortion, but there are few African countries involved. The products concerned, misoprostol or mifepristone, facilitate early abortions. They have few side effects and a high rate of success. In Tunisia a trial introduction of mifepristone achieved a 91% success rate (Elul B. and al., 2001). This method is still only very narrowly available, but could help to limit the risks associated with abortion.

Emergency contraception should also limit the use of induced abortion. Several African countries have already put it on the market, or are in the process of doing so. This will give women a concrete opportunity to manage the risk of pregnancy ex post facto, and the unrestricted sale of such contraception will make it easier for women to access.

This review of abortion methods available to women demonstrates an apparent diversity of methods on offer. Although illegal in most countries, medicalized abortions conducted by medical staff are relatively frequent. These abortions are certainly less dangerous but are not totally risk-free, because the staff involved do not always have the necessary skills or provide a suitably sanitary environment. The implementation of manual vacuum aspiration methods, using simple technology, can only improve this situation.

Nevertheless, many abortions are performed using methods that are very harmful to the health or lives of women, as is proven by studies on abortion-related complications which show that women hospitalized for these reasons have for the most part used plants or overdoses of medication, or have inserted objects into the vagina. These highly dangerous methods are, as we have seen, mostly used by young women at great risk to their health.

Therefore it is important to alert women to the dangers presented by these methods of abortion, and to enable them to access reproductive health programmes so that they can better manage the situation.