Cambodia legalized abortion in 1997, but a new Ipas and Ministry of Health study shows that, more than a decade later, there are still a number of obstacles between women and safe abortion care. Investigators found that even with a liberal abortion law, large numbers of women are still terminating unwanted pregnancies on their own and continue to seek care for abortion complications.
The study, “Abortion-related complications in Cambodia” by Ipas Senior Research Associate Tamara Fetters and co-authors Vonthanak Saphonn, Carla Picardo and Tung Rathavy, appears in the July 2008 issue of BJOG: An International Journal of Obstetrics and Gynaecology. The first study of its kind to be conducted in Cambodia, it examines complications resulting from unsafe, induced abortion and miscarriage by exploring women’s treatment in the postabortion care (PAC) units of public health facilities.
Investigators included a nationally representative sample of public-sector facilities, including both health centers and hospitals. Women in Cambodia tend to first seek care in local health centers, rather than in hospitals; however, many of these clinics still refer women to large hospitals to receive postabortion care, creating an unnecessary delay in treatment.
According to the study, almost 32,000 women with abortion complications are treated annually in public health facilities; 42 percent of women seeking care had severe complications; 17 percent, more than 5,000 women, are in the second trimester of pregnancy. More than one-third of women, 37 percent, acknowledged having tried to terminate their pregnancies before seeking postabortion care.
“We knew this study would provide strong evidence about the demand for and utilization of PAC and safe abortion services in the country, as well as provide directions for making pregnancy safer and a baseline from which to measure change,” Fetters states.
Ipas is currently working with Options UK and the Cambodian Ministry of Health through the Reduction of Maternal Mortality Project to address the many gaps in training and service provision identified in the research. This study has provided strong evidence about the demand for and utilization of PAC and safe abortion services in the country, given direction for project activities and documented a baseline from which to measure change. Providers who are properly trained in abortion and postabortion care have the potential to significantly reduce abortion-related complications and injuries in Cambodia.
According to the World Health Organization (WHO), unsafe abortion causes as many as 5 million hospitalizations annually around the world, accounts for approximately 13 percent of maternal deaths and causes secondary infertility for close to 24 million women. Specific complications from unsafe abortion — hemorrhage, sepsis, peritonitis and trauma to the cervix, vagina, uterus and abdominal organs — show how an otherwise safe surgical procedure can become extremely dangerous when performed under unsanitary conditions by an unskilled provider. The rate of hospitalizations for complications of abortion in Cambodia is 9 per 1000 women. Although global evidence is limited, this rate can be compared to Bangladesh, where a government-sponsored menstrual regulation program limits unintended pregnancies, and only 3 women are hospitalized per 1000; the rate is much higher in Egypt and Uganda where researchers estimate that 15 per 1000 women seek care for abortion complications.
Investigators estimated the number and severity of abortion complications in Cambodia by collecting information on all abortion clients in health facilities during a one-month period. Cambodia is the third country to use this methodology, following earlier studies in South Africa and Kenya, and the article concludes with a comparative view of the key findings from each of these studies. The three represent an extraordinary body of work with significant policy and practice relevance. There is currently a similar study taking place in Ethiopia with preliminary results by the end of 2008.
Fetters’ article is a reminder that improving abortion law is not the only step in reducing deaths and injuries from unsafe abortion; efforts must be made to scale up and improve health-care services, as well as address the lingering stigma surrounding safe abortion. Not only is safe abortion care and postabortion care an integral part of high-quality, comprehensive health care — in many parts of the world, it means the difference between life and death.
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