Clandestine Abortion in Bangui, Central African Republic

Introduction: The clandestine abortions remain a major health problem in developing countries including the Central African Republic. At the main maternity hospital of Bangui in the Central African Republic, a study conducted in 2000 indicates that clandestine abortions (CAs) accounted for 43.4% of all abortions recorded in the service. The purpose of our study was to evaluate the evolution of CAs about the health care management efforts made over the last 4 years. Patients and Methods: We conducted a prospec-tive descriptive and analytical study over a period of 4 years (from January 2016 to December 2019). This study focused on the complications of clandestine abortions that occurred during the course of our study at the HCB refer-ence maternity hospital. Results: We identified 267 clandestine abortions for 783 spontaneous abortions. The frequency of CAs was 34.1%. The highest number of CAs was observed in patients aged between 20 and 24 years with an average age of 23.7 years. The average parity was 2.6. It appeared in our study that students were the most represented (40.8%). Rescuers were the most incriminated (29.2%) in clandestine abortion (CA). Infectious complications predominated in (79.1%) of cases. Antibiotic therapy was almost systematic (96.6%). Laparotomy was performed in (38.9%) cases. The proportion of deceased women who had a pregnancy of more than 12 weeks was higher with a statistically significant difference (p < 0.001). Conclusion: Abortion affects all women regardless of age, parity, marital status and so-cio-economic status.


Introduction
Around the world, women have always used induced abortions to stop unwanted pregnancies inducing high rates of maternal morbidity and mortality, including uterine sepsis. Despite its illegal nature and stigmatization in several countries south of the Sahara, some women do not hesitate to resort to clandestine methods and this in dangerous conditions. The complications of these clandestine abortions are responsible for 13% of maternal deaths according to the World Health Organization [1]. However, data on abortion in sub-Saharan Africa are still rare and non-representative [2]. In the Central African Republic, voluntary termination of pregnancy is prohibited by law (article 190 of the Central African Republic Penal Code). This forces women to perform clandestine abortions (CAs) at the risk of their lives. A study conducted 15 years ago indicates that CAs accounted for 43.4% of all abortions recorded in the service [3].
Despite the recommendations made to reduce the incidence of these accidents, there are still many CAs presenting in the maternal emergency service of the Hôpital Communautaire of Bangui in the Central African Republic. This was another reason for undertaking this study, which has the following objectives: to provide knowledge about the burden of CAs in the Hôpital Communautaire of Bangui in order to contribute to the reduction of morbidity and mortality related to the complications of these abortions.

Methods
We conducted a descriptive and analytical cross-sectional study over a period of 4 years (from January 2016 to December 2019). This study focused on the complications of clandestine abortions that occurred during our study at the maternity of Hôpital Communautaire. The study population consisted of women admitted to the service for complications of CAs. The size of our sample was determined by the number of patients meeting the inclusion criteria after their informed consent. Patients admitted for spontaneous abortion were not included in the study. For each patient selected, the following parameters were studied: socio-demographic characteristics; the term gestational; gynecological and obstetric history; motivations for abortion; the method used to induce abortion; the professional profile of the abortionist; the complications found; the treatment administered; the duration of hospitalization; evolution and prognosis. Data collection was performed using a structured questionnaire. The data was entered and analyzed on Epi-info version 7. Pearson's Chi2 comparison statistical tests were performed and the threshold of statistical significance was 5%.
Informed consent was not required from patients.

Results
A total number of 267 cases of clandestine abortions were identified. The proportion of CAs was 25.4% of all abortions. The average age was 23.6 years, with the highest number of clandestine abortions in the 20 to 24 age group. The av- erage parity was 2.6. Nulliparas accounted for 23.2%. The marital status of these women showed that a proportion of 82.2% was single. Students were the most represented (40.8%) ( Table 1). These clandestine abortions were performed by first aiders in 87.5% of cases. The main method used was curettage (65.9%). In. 9% of the cases traditional potions were used (Table 2).
Infectious complications predominated in 79.1% of cases, represented by endometritis (36.3%), pelviperitonitis (31.4%) and severe sepsis (11.2%). Hemorrhagic complications were found in (13.8%) of the cases. The exit of the loops by the genital sector represented 2.7%. The medical treatment was based on resuscitation and systematic antibiotic therapy (96.6%). Laparotomy for peritoneal lavage was the treatment in case of certain pelvic peritonitis 38.9% of cases, hysterectomy in 2.6% of cases, for total disfigurement of the uterus (Table 3).
We recorded 12.7% of deaths. The proportion of deceased women who had a pregnancy of more than 12 weeks of amenorrhea was higher with a statistically significant difference p < 0.001 (Table 4). No other factors such as practitioners and method used were found to affect the prognosis.

Discussion
The results of this work reveal the seriousness of CAs with a prevalence of 25.4%. This finding is made by several African studies that find rates ranging from 23% to 37% [4] [5]. A study conducted 15 years ago in the service shows a prevalence of 43.4% [3]. Sexuality issues are still taboo in the family and girls enter sexual life without proper education [6]. This justifies a prevalence of under-25s (59.9%) practicing the most CAs. This trend is almost the same as that found by Mayi-Tsonga in Gabon in 2009 [7].
The primiparous were the most represented (32.9%). These primiparous young people often do not master the use of contraceptive methods and thus end up with an unwanted pregnancy [8] [9]. Births out of wedlock are often socially sanctioned, abortion is for these young singles (82.2%) the only possibility not to compromise their future and a future marriage. Some authors have found a predominance of nulliparas [6] [8]. Regarding the qualification of the abortionist, we found that 29.2% of the perpetrators were unqualified health workers, which is consistent with Ekanem's studies [10]. On the other hand, Orijiet Andriamifidison found during their studies a predominance of self-abortion [11] [12]. These unskilled workers often use mechanical methods (65.9%), all of which are dangerous because they are performed in non-septic conditions with unskilled personnel who do not know the basic rules of asepsis, act in haste, and are not concerned. hardly respect for the rule of art. We must also note the wandering of the victims and the concern of the girl to hide her condition and her act. All of these factors give rise to the predominance of infectious complications encountered during our study (81.8%). Postabortion care is also inadequate (self-medication) and delays the admission of patients to the appropriate structures, thus lengthening the time to treatment [13] [14] [15]. The symptomatic and etiopathogenic treatment was based essentially on antibiotic therapy which was systematic, given the context of lack of asepsis where these abortions were performed. Surgically, manual intrauterine aspiration was the most commonly used procedure. This is consistent with the studies of Lokossouau in Benin [16]. Laparotomy was necessary in cases of uterine perforation, pelviperitonitis and exenteration. Death is a major risk for women who perform clandestine abortions. We recorded 32 deaths, or 12.7%. Taking into account the difference between the mortality rate of our study, which reflects the reality in other African countries, and the very low rate observed in countries where there has been legalization of abortion, the debate on The liberalization of abortions deserves to be opened especially since the punitive and repressive laws previously in force in the Central African Republic have not proved their worth [1] [3] [5] [16].

Conclusion
Abortion affects all women regardless of age, parity, marital status and socio-economic status. He intervenes at different times in the cycle of family life. However, we found that complications of clandestine abortions remain an important factor in maternal mortality, while family planning needs are poorly covered. From this point of view, action will have to be taken to restore the importance of family planning as a contribution to the reduction of clandestine abortions. We do not forget the role of the community in raising awareness and adopting responsible sexual behavior among young people.

Authors' Contributions
NNR, KA and SA were involved in study design, data acquisition, analysis and interpretation of results and drafting the manuscript. MDK, MMS and GCE performed data collection and interpretation. Data acquisition JRM and PM performed laboratory analyses. AM was involved in data analysis, interpretation of results and drafting the manuscript. All authors participated in the manuscript writing and approved the final version of this manuscript.