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Unsafe abortion and abortion care in Khartoum, Sudan

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Abstract

Unsafe abortion in Sudan results in significant morbidity and mortality. This study of treatment for complications of unsafe abortion in five hospitals in Khartoum, Sudan, included a review of hospital records and a survey of 726 patients seeking abortion-related care from 27 October 2007 to 31 January 2008, an interview of a provider of post-abortion care and focus group discussions with community leaders. Findings demonstrate enormous unmet need for safe abortion services. Abortion is legally restricted in Sudan to circumstances where the woman's life is at risk or in cases of rape. Post-abortion care is not easily accessible. In a country struggling with poverty, internal displacement, rural dwelling, and a dearth of trained doctors, mid-level providers are not allowed to provide post-abortion care or prescribe contraception. The vast majority of the 726 abortion patients in the five hospitals were treated with dilatation and curettage (D&C), and only 12.3% were discharged with a contraceptive method. Some women waited long hours before treatment was provided; 14.5% of them had to wait for 5-8 hours and 7.3% for 9-12 hours. Mid-level providers should be trained in safe abortion care and post-abortion care to make these services accessible to a wider community in Sudan. Guidelines should be developed on quality of care and should mandate the use of manual vacuum aspiration or misoprostol for medical abortion instead of D&C. Résumé Les avortements à risque au Soudan provoquent une morbidité et une mortalité importantes. Cette étude du traitement des complications de l'avortement à risque dans cinq hôpitaux de Khartoum, Soudan, a examiné des dossiers hospitaliers et enquêté auprès de 726 patientes ayant demandé des soins liés à l'avortement du 27 octobre 2007 au 31 janvier 2008. De plus, un entretien a eu lieu avec un prestataire de soins post-avortement et des discussions de groupe avec des responsables communautaires. L'étude révèle un énorme besoin insatisfait de services d'avortement sûr. La loi soudanaise limite l'avortement aux grossesses résultant d'un viol ou mettant en danger la vie de la femme. Il est difficile d'avoir accès aux soins post-avortement. Dans un pays rural aux prises avec la pauvreté, les déplacements internes et une pénurie de médecins formés, les prestataires de niveau intermédiaire ne sont pas autorisés à donner des soins post-avortement ou à prescrire des contraceptifs. La grande majorité des 726 patientes ont avorté par dilatation et curetage et seulement 12,3% sont sorties de l'hôpital avec une méthode de contraception. Quelques femmes devaient attendre longtemps avant d’être traitées ; 14,5% d’entre elles avaient dû patienter pendant 5-8 heures et 7,3% pendant 9-12 heures. Les prestataires de niveau intermédiaire doivent être formés à l'avortement sûr et aux soins post-avortement afin que ces services soient accessibles à davantage de Soudanaises. Il faut préparer des directives sur la qualité des soins et rendre obligatoire l'utilisation de l'aspiration manuelle ou du misoprostol pour l'avortement médicamenteux, de préférence à la méthode par dilatation et curetage. Resumen El aborto inseguro en Sudán causa considerable morbilidad y mortalidad. Este estudio del tratamiento de las complicaciones del aborto inseguro en cinco hospitales de Jartum, en Sudán, comprendió una revisión de los registros hospitalarios, una encuesta de 726 pacientes que buscaban servicios de aborto entre el 27 de octubre de 2007 y el 31 de enero de 2008, una entrevista de un proveedor de atención postaborto y discusiones en grupos focales con líderes de la comunidad. Los resultados demuestran la enorme necesidad insatisfecha de servicios de aborto seguro. En Sudán, el aborto es limitado por la ley a circunstancias en que la vida de la mujer corre peligro o casos de violación. La atención postaborto no es fácil de acceder. En un país donde se lucha contra la pobreza, el desplazamiento interno, viviendas rurales y una escasez de médicos capacitados, a los prestadores de servicios de nivel intermedio se les prohíbe brindar atención postaborto o recetar anticonceptivos. La gran mayoría de las 726 pacientes encuestadas en los cinco hospitales fueron tratadas con dilatación y curetaje (D&C) y sólo el 12.3% recibió un método anticonceptivo antes de egresar. Unas de las mujeres tuvieron que esperar largas horas antes de recibir tratamiento. El 14.5% tuvo que esperar 5-8 horas; el 7.3%, 9-12 horas. Los prestadores de servicios de nivel intermedio deberían recibir capacitación en la atención segura del aborto y la atención postaborto para ampliar el acceso a estos servicios en Sudán. Se deberían elaborar directrices sobre la calidad de la atención, que exijan el uso de la aspiración manual endouterina o el misoprostol en los procedimientos de aborto con medicamentos, en vez de D&C.
©2009 Reproductive Health Matters.
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Reproductive Health Matters 2009;17(34):7177
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Unsafe abortion and abortion care in Khartoum, Sudan
Joyce Kinaro,
a
Tag Elsir Mohamed Ali,
b
Rhonda Schlangen,
c
Jessica Mack
d
a Senior Program Officer, Planned Parenthood Federation of America (PPFA), Africa Region, Nairobi, Kenya.
E-mail: jkinaro@yahoo.com
b Obstetrics and Gynaecology Consultant, Academy of Medical Sciences & Technology; and Project Director,
Safe International, Khartoum, Sudan
c Senior Research and Evaluation Manager, International Division, PPFA, New York, NY, USA
d Program Associate, International Division, PPFA, New York, NY, USA
Abstract: Unsafe abortion in Sudan results in significant morbidity and mortality. This study of
treatment for complications of unsafe abortion in five hospitals in Khartoum, Sudan, included
a review of hospital records and a survey of 726 patients seeking abortion-related care from
27 October 2007 to 31 January 2008, an interview of a provider of post-abortion care and focus
group discussions with community leaders. Findings demonstrate enormous unmet need for safe
abortion services. Abortion is legally restricted in Sudan to circumstances where the woman's
life is at risk or in cases of rape. Post-abortion care is not easily accessible. In a country struggling
with poverty, internal displacement, rural dwelling, and a dearth of trained doctors, mid-level
providers are not allowed to provide post-abortion care or prescribe contraception. The vast majority
of the 726 abortion patients in the five hospitals were treated with dilatation and curettage
(D&C), and only 12.3% were discharged with a contraceptive method. Some women waited long
hours before treatment was provided; 14.5% of them had to wait for 5-8 hours and 7.3% for
9-12 hours. Mid-level providers should be trained in safe abortion care and post-abortion care to
make these services accessible to a wider community in Sudan. Guidelines should be developed on
quality of care and should mandate the use of manual vacuum aspiration or misoprostol for medical
abortion instead of D&C. ©2009 Reproductive Health Matters. All rights reserved.
Keywords: unsafe abortion, post-abortion care, abortion methods, contraception and unplanned
pregnancy, abortion law and policy, mid-level providers, Sudan
IN Sudan, due in part to infrastructural weak-
nesses in health care and decades of civil
strife, no national data exist on sexual and
reproductive health, including on induced and
unsafe abortion. With a high number of inter-
nally displaced persons living in environments
characterised by poverty and gender-based vio-
lence, access to health services is often tenuous.
In some situations, women and girls submit to
sexual abuse in order to obtain food and basic
necessities.
1
In addition, a restrictive abortion
law coupled with strong cultural and religious
stigma against abortion mean not only that it
is difficult to access safe abortion services, but
also that it is difficult for people to speak openly
about the topic at the community level, let alone
to gather information.
Abortion is legal in Sudan only in cases of
rape and when the woman's life is at risk. In
cases of rape, the woman must inform the police
immediately, who should then provide her with
a form (Form No.8), which, in the event of preg-
nancy, she can take to the nearest hospital for
the assurance of a safe abortion. Post-abortion
care (PAC) is also allowed in Sudan.
Women in Sudan seek unsafe abortions for a
range of reasons, including lack of knowledge
about their rights under the law, lack of access
to safe services and lack of resources to access
safe services. This is probably as true now as it
71
was in 1976, when one of the few studies on
this subject was published.
2
Post-abortion care
(PAC) is at its best a comprehensive strategy to
address the problem of unsafe abortion, includ-
ing treatment of complications caused by unsafe
procedures, provision of post-abortion contra-
ceptives, and engagement of the community on
these issues.
3
Treatment for most complications
can be carried out by mid-level providers, includ-
ing nurses and midwives, with training. PAC is
widely permitted in countries where abortion is
legally restricted and when widely available, can
be a key life-saving intervention for women.
4,5
Several international and regional human rights
frameworks, including the African Union's Sexual
and Reproductive Health and Rights Continental
Policy Framework and the Maputo Protocol, pro-
vide clear guidelines for addressing the issue of
unsafe abortion, framing access to safe abortion,
including post-abortion care, and other reproduc-
tive rights as human rights.
6,7
Despite this, few
African countries have reproductive health laws
that allow access to safe abortion services or ade-
quately ensure access to quality post-abortion
care. Even in countries where the law more liber-
ally allows for access to safe abortion, such as in
Ethiopia and South Africa, stigma and conscien-
tious objection by providers continue to restrict
access in practice.
8
Unintended pregnancy rates are high in Sudan.
This is due in part to an extremely low contracep-
tive prevalence rate fewer than 10% of women of
reproductive age use contraception
9
but also due
to the high level of displacement among much of
the population, for whom there is a lack of access
to contraceptive services. Current estimates sug-
gest that 4.9 million people are internally dis-
placed as a result of ongoing conflicts with
250,000 new cases in Southern Sudan in 2009
alone.
10
Women and girls who are internally dis-
placed are particularly vulnerable to sexual vio-
lence and rape, which contributes to unintended
pregnancy and often unsafe abortions.
8,11
These
and other factors, including the restrictive abor-
tion law, mean that Sudan has one of the highest
maternal mortality ratios in the world, estimated
by UNICEF to be 1,107 deaths per 100,000 live
births,
12
a significant proportion of which may
be attributed to unsafe abortion.
In Sudan, the majority of the population live
in rural, impoverished areas, where doctors are
few and where mid-level providers, including
midwives and nurses, form the backbone of
the health care system, providing for the vast
majority of primary health care needs. From
1990 to 2004, it was estimated that there were
just 22 doctors per 100,000 people in Sudan, a
figure which may not include the south of the
country,
13
where the situation is worse. Current
protocols dictate, however, that legal abortion,
post-abortion care and the prescription of con-
traceptives must be provided only by doctors
in Sudan. The practical effect of these guide-
lines is to restrict access to services for much of
the population.
The study
The study was conducted in collaboration with
Safe International, a local non-governmental
organisation based in Khartoum, as a baseline
study to guide future project implementation.
It was carried out over a period of three months,
between 27 October 2007 and 31 January 2008.
The aim was to gather new information on safe
abortion services and PAC in Sudan, the quality of
care provided, the methods of abortion used, and
the characteristics of the women seeking these
services, in five referral hospitals in Khartoum.
Secondly, it aimed to discover attitudes and know-
ledge of community leaders on abortion.
Due to limited resources, the study was lim-
ited to Khartoum as part of a larger, planned
reproductive health project. As the capital of
Sudan and a centre of economic opportunity,
Khartoum has a diverse population, comprised
of internally displaced people and people from
all over the country. Thus, the information gath-
ered will represent, at least to some degree, a
wider range of communities, and can be used to
inform interventions to improve access to safe
abortion services beyond Khartoum.
In addition to review of hospital medical
records, the study relied on a survey of women
admitted to the study hospitals for abortion or
post-abortion care. Due to the cultural sensi-
tivity and criminalisation of abortion in Sudan,
the veracity of this self-reported data may be
undermined, particularly among women who
have undergone induced abortions outside the
parameters of the law and who have then pre-
sented with complications to the hospital. Even
data such as marital status may have been self-
censored, to avoid stigma.
J Kinaro et al / Reproductive Health Matters 2009;17(34):7177
72
Data and methods
Several data collection methods were used,
including a survey of women patients, aged
15-49, seeking abortion or post-abortion care
during the three-month study period at one of
five hospitals in Khartoum, collection of data
from their hospital medical records, focus group
discussions with community leaders and an in-
depth interview with a mid-level provider.
The survey was field tested with a sample of
50 patients. The inclusion criteria for survey par-
ticipants included women aged 15-49 from com-
munities in both Northern and Southern Sudan,
Muslims and non-Muslims, who had obtained
abortion services at Khartoum Teaching Hospital,
Academy Charity Hospital, Ibrahim Malik Hos-
pital, Bashir Hospital and Turkey Hospital in
Khartoum. 726 women agreed to participate.
Ethical approval was obtained from the
Sudan University of Sciences and Technology,
as well as from all five hospitals, which reviewed
the protocol. Verbal consent to participate was
given by all participants. Patients were reassured
that their names and information would remain
confidential for study purposes, and data collec-
tors were trained and supervised to enforce con-
fidentiality. Quantitative data were analysed
using SPSS (Statistical Package for Social Science).
Qualitative analysis used a focus group analy-
sis guide.
14
In order to determine diagnosis and treatment
initially, hospital records were reviewed for the
726 women. Data obtained included marital
status, education level, occupation, reproductive
history, including parity, gestation, circumci-
sion, and method of contraception used. Records
were also analysed for presenting complaints,
results of physical examination upon presenta-
tion, intervention treatment, type of anaesthesia,
and recovery notes made by the doctor.
All 726 patients whose records were reviewed
answered survey questions on overall patient
satisfaction, friendliness of staff, adequacy of
information on abortion provided, privacy of
services, ability of staff to answer their questions,
waiting time, level of acceptability of pain from
the procedure, counselling and information on
contraception, provision of a method, and whether
a follow-up appointment was scheduled.
Opinion leaders from both Muslim and Chris-
tian communities in Khartoum, both women and
men, were contacted through referral and invited
to participate in the study. Seven men and eight
women agreed. They were divided by sex into
two focus groups for discussion, in order to pro-
vide a greater degree of confidentiality and com-
fort in expression of opinions. The two groups
were asked about the definition of abortion, their
knowledge of the abortion law in Sudan, their
knowledge of traditional methods of inducing
abortion, the extent of abortion, and what the
complications were of unsafe abortion performed
in the community. In addition, one mid-level
provider trained in post-abortion care was inter-
viewed on the practice of mid-level providers
with regard to contraception, post-abortion care
and provision of abortions.
Women who came for abortion care and
services provided
Most of the women seeking abortion services
were aged 2039, had completed primary or
secondary education, and were married and
unemployed (Table 1). Most had had either none
or 1-2 previous abortions. Incomplete abortion
due to unsafe procedures is clearly an issue in
Khartoum, as the vast majority of the women
seeking services (96.7%) came for treatment of
post-abortion complications (Table 2). Presenting
complaints recorded included multiple symptoms
of vaginal bleeding, fever and abdominal pain.
Four women had foreign bodies still embedded
in their uterus when admitted.
The quality of care of these services is also
clearly an issue, including long waiting times
reported by the women, use of D&C in almost
all cases for treatment, and low levels of contra-
ceptive counselling and uptake of a method
(Table 2). Women waited long hours before
treatment was provided; 53 of them had to wait
for 9-12 hours. The majority of women (87.2%)
had a D&C with general anaesthesia; only 4.4%
were treated with MVA and 3.6% with miso-
prostol for both post-abortion and safe abor-
tion care.
Most staff were perceived as respectful and
caring, and explained the abortion procedure
sufficiently to satisfy most of the women, but
less than half the women said they were offered
a follow-up appointment or told to come back
if they experienced further complications or
had other concerns. Only a third were given
contraceptive information and counselling and
J Kinaro et al / Reproductive Health Matters 2009;17(34):7177
73
only 12.3% went home with a contraceptive
method (Table 3).
Knowledge and perceptions of community
leaders and a mid-level provider
There is widespread knowledge of abortion at all
levels of the community and recourse to abortion
is quite common, according to the community
leaders interviewed. Unsafe abortion is increas-
ingly being seen as a serious social and public
health issue in Sudan. They also acknowledged
the often fatal consequences of unsafe abortion.
Yes, I've heard and seen many of the complica-
tions of abortion. The main causes of abortion
complications seem to be resulting from the use
of herbs, and the inadequacy, inaccessibility and
unaffordability of proper care. Complications of
abortion start from severe abdominal pain and
severe bleeding, infection and ultimately can
lead to death. Those who do not die from unsafe
abortion usually become infertile or develop some
kind of disease.(Woman, age 36)
Community members reported that women usu-
ally go to midwives, whether trained or not, to
terminate their pregnancies, especially unmar-
ried women who become pregnant, in order to
avoid strict cultural and religious condemnation
of extra-marital relationships. The perception is
that women find it easier to approach traditional
and mid-level providers for reasons of confi-
dentiality and the quality of care they receive.
Women may expect a greater degree of confi-
dentiality and are less afraid of being reported,
since mid-level providers are offering a service
they are not legally allowed to offer.
Women feel more comfortable going to mid-
wives because they just pay and in return can
abort secretly. But when they go to doctors they
will be insulted and even abused. For this reason,
[women] often prefer being treated by an untrained
provider rather than going to a trained doctor.
(Woman, age 40)
J Kinaro et al / Reproductive Health Matters 2009;17(34):7177
74
Community leaders also cited different tradi-
tional methods to self-induce abortions in both
North and South Sudan, including drinking herbs,
ingesting various drugs and poisons, and insert-
ing objects into the uterus. Due to the stigma of
pregnancy outside marriage, women are often
assisted by their families to do this, to protect
the family's honour.
The in-depth interview with the mid-level
provider trained in post-abortion care revealed
the disparity between the accessibility of mid-
level providers for the majority of the population,
and the strict limits on the services they are able
to provide. Because contraceptives are legally
prescribed only by doctors, they often write out
the prescription and refer patients to mid-level
providers, who fill the prescription and distribute
methods. On the other hand, although mid-level
providers are not legally allowed to provide sur-
gical services such as post-abortion care using
MVA, some mid-level providers have been
trained by non-governmental organisations, but
are not yet able to provide such services openly.
Discussion
Currently, a small number of doctors are provid-
ing safe abortion and post-abortion care to a
small number of women in hospital settings.
In contrast, mid-level providers, including
nurses and midwives, are accessible at the com-
munity level and are often the first choice of
women needing abortions who are concerned
about stigma, confidentiality and the discom-
fort of accessing services in a hospital setting.
Although these providers are not allowed to
offer legal abortions or post-abortion care ser-
vices, some are clearly doing so and it would
be far better for them to be permitted to do so,
so that their training can be ascertained and
they can be held accountable for providing good
quality services. Many more nurses and mid-
wives have the capacity to be trained, and both
these steps would enable far greater access to
safe services for women in the wider community,
especially in rural areas where doctors are scarce.
Quality of care even in the hospital setting is
a critical issue. While some women waited only an
hour for treatment, others waited up to 12 hours,
suggesting either understaffing, a lack of resources
or a lack of urgency in managing incomplete abor-
tion. Further research is needed to ascertain the
reasons for these delays in Khartoum's hospitals.
A recent study in Gabon also found delays in pro-
vision of treatment for complications of unsafe
abortion in the main maternity hospital in Libre-
ville, a mean wait of almost 24 hours.
15
In that
case, lack of staffing and resources were not an
issue. The authors of that study state:
It appears that in the difficult environment of
an overcrowded maternity ward, where several
emergency cases may compete for attention, the
stigma of illegal abortion may lead staff to over-
look women with abortion complications without
considering the potentially fatal consequences of
doing so.
15
Additionally, only a third of the women in this
study were provided with contraceptive coun-
selling and information and only 12.3% of
women went home with a method. While con-
traceptive use overall is still quite low in Sudan,
the unmet need for family planning for preven-
tion of unwanted pregnancies is critical. Again,
thefactthatmid-levelproviders are not per-
mitted to prescribe contraceptives, although they
may distribute them, further limits access to con-
traception for women and men in the commu-
nity. Regulations should be changed to allow
them to do so.
16
J Kinaro et al / Reproductive Health Matters 2009;17(34):7177
75
MVA and medical abortion are safer and less
expensive than D&C, and do not require general
anaesthesia. The widespread reliance on D&C
for most abortions in all five hospitals, a method
that is obsolete in the developed world, is anti-
quated and unsafe. The World Health Organiza-
tion (WHO) has long recommended that all first
trimester terminations should be carried out
either medically (using mifepristone and miso-
prostol or misoprostol alone) or with MVA.
17
Yet most of the women in this study, of whom
more than 86% were in the first trimester, under-
went evacuation of the uterus using D&C. It is
therefore important to advocate that the govern-
ment amend current guidelines and regulations,
in line with WHO recommendations mandating
the use of MVA and medical abortion and dis-
seminate them widely to providers, in order to
ensure the effectiveness, safety and accessibility
of services. Services should be monitored regu-
larly to ensure protocols are being followed.
Lastly, women in Sudan should be informed
of their right to have a safe abortion within
the law, and cultural and other beliefs that stand
in their way must be addressed. Safe abortion
services must be available within the law and
easily accessible to all women. In addition, the
government should review the law to expand
indications for safe abortion.
Acknowledgements
Special thanks to Dr Bashir A Bashir, the con-
sultant in the study, data collection and analysis
team: Hanan Satti, Eshrga Baldo, Mohamed
Uthman, and many stakeholders including reli-
gious leaders, community leaders and service
providers. Thank you also to Dr Sarah Onyango,
for supporting PPFA's programme work in Sudan.
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Résumé
Les avortements à risque au Soudan provoquent
une morbidité et une mortalité importantes.
Cette étude du traitement des complications de
l'avortement à risque dans cinq hôpitaux de
Khartoum, Soudan, a examiné des dossiers
hospitaliers et enquêté auprès de 726 patientes
ayant demandé des soins liés à l'avortement du
27 octobre 2007 au 31 janvier 2008. De plus, un
entretien a eu lieu avec un prestataire de soins
post-avortement et des discussions de groupe
avec des responsables communautaires. L'étude
révèle un énorme besoin insatisfait de services
d'avortement sûr. La loi soudanaise limite
l'avortement aux grossesses résultant d'un viol
ou mettant en danger la vie de la femme. Il est
difficile d'avoir accès aux soins post-avortement.
Dans un pays rural aux prises avec la pauvreté,
les déplacements internes et une pénurie de
médecins formés, les prestataires de niveau
intermédiaire ne sont pas autorisés à donner
des soins post-avortement ou à prescrire des
contraceptifs. La grande majorité des 726 patientes
ont avorté par dilatation et curetage et seulement
12,3% sont sorties de l'hôpital avec une méthode
de contraception. Quelques femmes devaient
attendre longtemps avant dêtre traitées ;
14,5% dentre elles avaient dû patienter pendant
5-8 heures et 7,3% pendant 9-12 heures. Les
prestataires de niveau intermédiaire doivent
être formés à l'avortement sûr et aux soins
post-avortement afin que ces services soient
accessibles à davantage de Soudanaises. Il faut
préparer des directives sur la qualité des soins et
rendre obligatoire l'utilisation de l'aspiration
manuelle ou du misoprostol pour l'avortement
médicamenteux, de préférence à la méthode par
dilatation et curetage.
Resumen
El aborto inseguro en Sudán causa considerable
morbilidad y mortalidad. Este estudio del
tratamiento de las complicaciones del aborto
inseguro en cinco hospitales de Jartum, en
Sudán, comprendió una revisión de los registros
hospitalarios, una encuesta de 726 pacientes
que buscaban servicios de aborto entre el 27 de
octubre de 2007 y el 31 de enero de 2008, una
entrevista de un proveedor de atención postaborto
y discusiones en grupos focales con líderes de la
comunidad. Los resultados demuestran la enorme
necesidad insatisfecha de servicios de aborto
seguro. En Sudán, el aborto es limitado por la
ley a circunstancias en que la vida de la mujer
corre peligro o casos de violación. La atención
postaborto no es fácil de acceder. En un país donde
se lucha contra la pobreza, el desplazamiento
interno, viviendas rurales y una escasez de médicos
capacitados, a los prestadores de servicios de
nivel intermedio se les prohíbe brindar atención
postaborto o recetar anticonceptivos. La gran
mayoría de las 726 pacientes encuestadas en los
cinco hospitales fueron tratadas con dilatación y
curetaje (D&C) y sólo el 12.3% recibió un método
anticonceptivo antes de egresar. Unas de las
mujeres tuvieron que esperar largas horas antes
de recibir tratamiento. El 14.5% tuvo que esperar
5-8 horas; el 7.3%, 9-12 horas. Los prestadores
de servicios de nivel intermedio deberían recibir
capacitación en la atención segura del aborto y
la atención postaborto para ampliar el acceso a
estos servicios en Sudán. Se deberían elaborar
directrices sobre la calidad de la atención, que
exijan el uso de la aspiración manual endouterina
o el misoprostol en los procedimientos de aborto
con medicamentos, en vez de D&C.
J Kinaro et al / Reproductive Health Matters 2009;17(34):7177
77
... The adverse effects of induced abortions are not deterrent factors enough as several studies have shown a substantial percentage of women secure more than one abortion during their reproductive lifetime [8][9][10][11]. In Sudan, for example, a study in five hospitals showed that over 40 % of women pursuing medical care for problems of unsafe abortion had a history of at least one earlier unsafe abortion [10]. Also, research in Ethiopia revealed that among women looking for abortion-related services, the incidence of history abortion was 30 % [11]. ...
... The adverse effects of induced abortions are not deterrent factors enough as several studies have shown a substantial percentage of women secure more than one abortion during their reproductive lifetime [8][9][10][11]. In Sudan, for example, a study in five hospitals showed that over 40 % of women pursuing medical care for problems of unsafe abortion had a history of at least one earlier unsafe abortion [10]. Also, research in Ethiopia revealed that among women looking for abortion-related services, the incidence of history abortion was 30 % [11]. ...
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Induced abortion is a common practice for women worldwide; nevertheless, the practice of unsafe abortion rate in Ghana is in height and is a constant issue of public health concern. Objective: The main aim of the study was to identify predictive factors associated with induced abortion among women in Ghana. Methods: Ghana Maternal Health Survey data was used for this study to do an analytic cross-section study. Data analysis was done using SPSS version 20. The association between dependent and independent variables was explored using chi-square and logistic regression. Statistical significance was set at p < 0.05. Results: In this study, the prevalence of induced among the respondents was 14.8%, the prevalence was higher (25.5%) in Greater Accra Region and lower (3.2%) in Northern Region. All under-studied independent variables through chi-square analysis were associated with induced abortion with significance. However, in advance analysis through binary logistics regression model predictor factors of induced abortion in Ghana identified were; the age of the respondents’, region of orientation, religious affiliation, marital status, ethnicity, exposure to mobile phone and newspaper, and age at first sex. The logistic regression model appropriately explained the outcome variable (induced abortion) since the Hosmer-Lemeshow goodness-of-fit test p-value was more than 0.05 (X2 (8) = 4.428, P = .817). Conclusion: The prevalence of abortion in Ghana is still high, hence the need for increase public education on contraceptive use and the adverse effects of abortion through the use of modern media can go a long way to reduce the incidence of induced abortion in Ghana.
... 6,7 The prevalence of RIA varied over the world, which ranged from 23.4% to 70% in developed countries, 8,9 and 16% to 40% in developing countries. 1,10 The prevalence of RIA among reproductive-age group women seeking abortion care services shows great variation in Ethiopia. It ranges from 20.3% to 34.9% in Debre Berhan Town and Debre Markos town health institutions, respectively. ...
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Introduction: Despite the advances in modern health care, maternal morbidity and mortality remain major problems in Ethiopia. Repeat-induced abortion is an indispensable contributor to this problem. Even though there are adverse effects on health, a significant proportion of Ethiopian women procure more than one abortion during their reproductive lifetime. This study aimed to determine the prevalence and associated factors of repeat-induced abortion in South Ethiopia, in 2020. Methods: An institution-based cross-sectional study design and a systematic random sampling technique were used to collect data from 410 samples of women. Data were collected using pre-tested and semi-structured interviewer-administered questionnaires. The data were coded and entered into EpiData version 4.6.2.0 before being exported to Statistical Package for Social Sciences (SPSS) version 26 for analysis. Variables with a p-value of less than 0.05 in binary logistic regressions were exported into multivariate logistic regression analysis. Finally, variables with a p-value of less than 0.05 in the multivariate logistic regression analysis were used to declare statistical significance. Result: The prevalence of repeat-induced abortion was found to be 35.4% (95% confidence interval = 30.7-40). Not facing a complication in prior abortion care, having more than two partners in the last 12 preceding months, perceiving abortion procedure as non-painful, having a sexual debut before the age of 18 years, and consuming alcohol have higher odds of repeat-induced abortion when compared with their counterparts. Conclusion: The prevalence of repeat-induced abortion in Hawassa city is high compared to studies conducted in other parts of Ethiopia. Not facing complications during previous abortion care, perceiving the abortion procedure as non-painful, alcohol consumption, having multiple sexual partners, and having a sexual debut before the age of 18 years are found to increase the chance of repeat-induced abortion.
... Figure 1 illustrate very interesting results which denote improvement in our PAC service, hence 66.1% treated with misoprostol, 33.7% treated with MVA and only 0.2% require sharp evacuation, despite the fact that obtained from study in capital of Sudan 2009 which concluded that, the commonly used method of treatment among 726 is dilatation and curettage (D&C). [10] Also, in Pakistan, instrumentation of the uterus was the commonest method of induction, used in 65% of cases. [11] Whereas, another study In Kenya MVA or electronic vacuum aspiration (EVA) used as treatment modality in 65% of abortion. ...
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Article
Background: Although there are safe and effective methods of abortion, unsafe abortions still widely spread, mainly in underdeveloped countries. Objective: Study of post abortion care services at Red Sea State to address rate and utilization of post-abortion care package. Methods: This is a descriptive (observational hospital-based study), conducted at Port Sudan Maternity hospital (May 2018– May 2019). The sample included all patients with inevitable and incomplete miscarriage. Results: The total admissions to emergency in gynaecological department during the study period was 9525 cases, of them 1077 cases of abortion, hence the rate was 11.3%. Spontaneous onset occurred in 631 (58.6%) and induced in 446 (41.4%). Surprisingly very few surgical evacuations done in 2 (0.2%). 710 (66.1%) evacuated by Misoprostol and MVA done for 362 (33.7%). Patients who received family planning and counseling were 223 (20.7%). Conclusion: in conclusion the rate of abortion was 11.3%, high incidence of induced abortion and high non-surgical evacuation. Utilization of care package is reasonable.
... Figure 1 illustrate very interesting results which denote improvement in our PAC service, hence 66.1% treated with misoprostol, 33.7% treated with MVA and only 0.2% require sharp evacuation, despite the fact that obtained from study in capital of Sudan 2009 which concluded that, the commonly used method of treatment among 726 is dilatation and curettage (D&C). [10] Also, in Pakistan, instrumentation of the uterus was the commonest method of induction, used in 65% of cases. [11] Whereas, another study In Kenya MVA or electronic vacuum aspiration (EVA) used as treatment modality in 65% of abortion. ...
Article
Background: Although there are safe and effective methods of abortion, unsafe abortions still widely spread, mainly in underdeveloped countries. Objective: Study of post abortion care services at Red Sea State to address rate and utilization of post-abortion care package. Methods: This is a descriptive (observational hospital-based study), conducted at Port Sudan Maternity hospital (May 2018-May 2019). The sample included all patients with inevitable and incomplete miscarriage. Results: The total admissions to emergency in gynaecological department during the study period was 9525 cases, of them 1077 cases of abortion, hence the rate was 11.3%. Spontaneous onset occurred in 631 (58.6%) and induced in 446 (41.4%). Surprisingly very few surgical evacuations done in 2 (0.2%). 710 (66.1%) evacuated by Misoprostol and MVA done for 362 (33.7%). Patients who received family planning and counseling were 223 (20.7%). Conclusion: in conclusion the rate of abortion was 11.3%, high incidence of induced abortion and high non-surgical evacuation. Utilization of care package is reasonable.
... Healthcare providers will prefer to wait or buy time until things happen on their own, or as well refer the patients. This, unfortunately, delays the care process, feeds obstetric violence and increases the risk of complications and death as described in other studies (Kinaro et al., 2009;Mayi-Tsonga et al., 2009). Referrals between colleagues or health facilities, therefore, reconcile discomfort and professional norms/obligations since the referral in medical norms is legitimate even if it may not be justified (Ouedraogo, 2016). ...
Article
Despite political commitments to address maternal deaths due to abortion, women and girls in Burkina Faso still face impediments to accessing post-abortion care (PAC) services, including stigma, high costs, and negative patient-provider relationships. Based on a three-year ethnographic study in Ouagadougou, Burkina Faso (2011-2014), this paper provides an in-depth examination of the experiences and perceptions of patients and healthcare providers when seeking or delivering PAC. Extensive participant observation of PAC service delivery was carried out in five primary and three referral health facilities, as well as in-depth interviews with 13 healthcare providers and 39 patients. Data were analyzed using a thematic analysis approach and discussed using relevant literature. Patients and providers conceptualized PAC as literally “womb washing’’, vividly reflecting on the realities around health risks of abortion, procreation and role of health providers. Moreover, women described PAC as a life-saving intervention capable of averting infections and other complications, but also bears significant risks of disclosure depending on the uterine evacuation technology used (manual vacuum aspiration versus medical abortion). In delivering PAC services, healthcare providers agonize over the dilemmas they face, mainly derived from their conceptualization of PAC services and how they cope with discomfort using PAC technology options. Our findings present the intersection between patients’ and providers' conceptions of PAC; and how these perceptions drive the choice of technology for uterine evacuation to mitigate stigma. We argue that these perceptions drive patient and healthcare provider practices around decision making to seek or deliver care, and patient-provider interactions in health facilities. These findings offer important guidance for interventions seeking to improve access and quality of PAC.
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Objective of Study: To assessment of nurse-midwives' knowledge and performance concerning with post-abortion Care. Methodology: A cross sectional descriptive analysis of (50) nurse midwives of this category of maternity nurse midwives was conducted in separate units of the Bint Al-Huda hospital between 19 January 2020 and 30 April 2020. The questionnaire's validity and reliability was calculated through a pilot test. Due to the condition in the nation and the governorate, the emergence of the Corona epidemic and the implementation of curfews, the questionnaire was submitted electronically and the questionnaire was completed by the nurses and midwives, data was processed using the SPSS edition (20). Results: The test showed that 22% of the test sampler replied correctly to Encourage the client to clear the toilet, 44% replied correctly to isolation of infected patients, 20% of the study sample responded correctly to the importance of hand washing, 35% responded correctly to Asses vaginal bleeding, 25% of the research sample responded correctly in, In terms of emotional assistance, 30 percent responded correctly,19 percent of the research sample replied with right Test vital signs. 38 percent of them correctly replied with regard to the patient's medical profile, 40 percent of the test group correctly replied with regard to Perineum care.
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Uterine perforation is a rare life threatening complication due to unsafe abortion by unqualified or untrained person. CASE: A 20 year old primigravida with 6 months ANC was referred to our hospital with the USG of uterine rupture and with a history of Dilation and curettage i/v/o anomalous baby, was in septic shock. There was also evidence of Sigmoid colon perforation. As a life saving measure Obstetric hysterectomy with colostomy done. Unsafe CONCLUSION: abortions are still in practice which has led to increased rate of mortality and morbidity. surgical intervention on a uterus of more than 20 weeks can be hazardous and should be terminated wisely.
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Background It is essential to provide comprehensive sexual and reproductive health (SRH) interventions to women affected by armed conflict, but there is a lack of evidence on effective approaches to delivering such interventions in conflict settings. This review synthesised the available literature on SRH intervention delivery in conflict settings to inform potential priorities for further research and additional guidance development. Methods We searched MEDLINE, Embase, CINAHL and PsycINFO databases using terms related to conflict, women and children, and SRH. We searched websites of 10 humanitarian organisations for relevant grey literature. Publications reporting on conflict-affected populations in low-income and middle-income countries and describing an SRH intervention delivered during or within 5 years after the end of a conflict were included. Information on population, intervention and delivery characteristics were extracted and narratively synthesised. Quantitative data on intervention coverage and effectiveness were tabulated, but no meta-analysis was undertaken. Results 110 publications met our eligibility criteria. Most focused on sub-Saharan Africa and displaced populations based in camps. Reported interventions targeted family planning, HIV/STIs, gender-based violence and general SRH. Most interventions were delivered in hospitals and clinics by doctors and nurses. Delivery barriers included security, population movement and lack of skilled health staff. Multistakeholder collaboration, community engagement and use of community and outreach workers were delivery facilitators. Reporting of intervention coverage or effectiveness data was limited. Discussion There is limited relevant literature on adolescents or out-of-camp populations and few publications reported on the use of existing guidance such as the Minimal Initial Services Package. More interventions for gender-based violence were reported in the grey than the indexed literature, suggesting limited formal research in this area. Engaging affected communities and using community-based sites and personnel are important, but more research is needed on how best to reach underserved populations and to implement community-based approaches. PROSPERO registration number CRD42019125221.
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At the 1994 ICPD, sub-Saharan African (SSA) states pledged, inter alia, to guarantee quality post-abortion care (PAC) services. We synthesized existing research on PAC services provision , utilization and access in SSA since the 1994 ICPD. Generally, evidence on PAC is only available in a few countries in the sub-region. The available evidence however suggests that PAC constitutes a significant financial burden on public health systems in SSA; that accessibility, utilization and availability of PAC services have expanded during the period; and that worrying inequities characterize PAC services. Manual and electrical vacuum aspiration and medication abortion drugs are increasingly common PAC methods in SSA, but poor-quality treatment methods persist in many contexts. Complex socioeconomic , infrastructural, cultural and political factors mediate the availability, accessibility and utilization of PAC services in SSA. Interventions that have been implemented to improve different aspects of PAC in the sub-region have had variable levels of success. Underexplored themes in the existing literature include the individual and household level costs of PAC; the quality of PAC services; the provision of non-abortion reproductive health services in the context of PAC; and health care provider-community partnerships. ARTICLE HISTORY
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1. Preamble 1.1. Need for developing case definitions and guidelines for data collection, analysis, and presentation for postpartum endometritis and infection following incomplete or complete abortion as adverse events following maternal immunization Remarkable progress has been made in the implementation of vaccinations against infectious diseases worldwide. Immunization of pregnant women is important because pregnancy is thought to modulate the immune system to tolerate a growing fetus, and this, along with the physiologic changes of pregnancy, may increase susceptibility to certain infectious diseases [1]. Immunizing the mother also provides direct protection via transplacental transfer of antibodies for the fetus during pregnancy and for the neonate following delivery. Pregnancy outcomes related to the administration of immunizations during pregnancy, however, have been less well studied. In particular, puerperal sepsis (infection of the female genital tract following childbirth or abortion/miscarriage) has not been well studied following maternal immunization. Puerperal sepsis is responsible for over 10% of maternal deaths worldwide and disproportionately occur in low- and middle-income countries (LMICs) [2,3]. Puerperal sepsis is defined by the World Health Organization (WHO) as infection of the genital tract occurring any time between the rupture of membranes or labour and the 42nd day postpartum. This definition encompasses both chorioamnionitis and postpartum endometritis or endomyometritis (PPE), two of the most common infections surrounding childbirth [4]. These complications are likely to be inconsistently reported. ICD10 codes for ‘‘sepsis following incomplete or complete abortion” (O03.87) and ‘‘endometritis following delivery” (O86.12) do not include any diagnostic criteria (see Figs. 1–3). Early identification and appropriate management of these infections is essential for the prevention of maternal and infant morbidity and mortality. Efforts have been made to standardize the definitions for maternal infectious conditions or sepsis in order to improve identification of the condition, facilitating timely treatment based upon prompt identification, and assessment of the burden of maternal puerperal sepsis across settings [5,6].
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This study is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of Cooperative Agreement No. HRN-A-00-98-00012-00 and In-house project number 5800-53084. The contents are the responsibility of the FRONTIERS Program and do not necessarily reflect the views of USAID or the United States Government. Linking family planning with postabortion services in Egypt i SUMMARY Effective linkage between postabortion evacuation services and family planning is essential to reduce the incidence of repeat unwanted pregnancy and unsafe abortion. This collaborative operations research study between FRONTIERS Program, TAHSEEN/ Catalyst Project, and the Egyptian Ministry of Health and Population (MOHP), with funds from USAID, was undertaken to test the feasibility, acceptability, and effectiveness of two models of integrating family planning services with postabortion services. The first model involves provision of family planning counseling to postabortion patients and referral to a clinic near their residence to receive a method. The second model involves, in addition, offering family planning methods to postabortion patients who are interested in immediate initiation of contraception. A companion study investigated pain management perceptions and practices of Egyptian patients and providers in relation to postabortion care in different types hospitals; the research methodology and results are provided in Appendix I of this report.
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Based on articles found on the PubMed and Popline databases on the provision of first-trimester abortion by mid-level providers, this article describes policies on type of abortion provider, comparative studies of different types of abortion provider, provider perspectives, and programmatic experience in Bangladesh, Cambodia, France, Mozambique, South Africa, Sweden, the United States of America and Viet Nam. It shows that it is safe and beneficial for suitably trained mid-level health-care providers, including nurses, midwives and other non-physician clinicians, to provide first-trimester vacuum aspiration and medical abortions. Moreover, it finds that projects in Kenya, Myanmar and Uganda have successfully trained nurse-midwives to provide post-abortion care for incomplete abortion with manual vacuum aspiration, and that studies in Ethiopia and India have recommended that providers such as auxiliary nurse-midwives should be trained in abortion service delivery to ensure that they provide safe abortions for low-income women. The paper recommends the authorization of all qualified mid-level health-care providers to carry out first-trimester abortions, and it also recommends the integration of training in providing first-trimester abortion care into basic education and clinical training for all mid-level providers and medical students interested in obstetrics and gynaecology. Finally, it calls for documentation of the role of mid-level providers in managing second-trimester medical abortions to further inform policy and practice.
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Continued political and civil unrest in low-resource countries underscores the ongoing need for specialised reproductive health services for displaced people. Displaced women particularly face high maternal mortality, unmet need for family planning, complications following unsafe abortion, and gender-based violence, as well as sexually transmitted diseases, including HIV. Relief and development agencies and UN bodies have developed technical materials, made positive policy changes specific to crisis settings and are working to provide better reproductive health care. Substantial gaps remain, however. The collaboration within the field of reproductive health in crises is notable, with many agencies working in one or more networks. The five-year RAISE Initiative brings together major UN and NGO agencies from the fields of relief and development, and builds on their experience to support reproductive health service delivery, advocacy, clinical training and research. The readiness to use common guidance documents, develop priorities jointly and share resources has led to smoother operations and less overlap than if each agency worked independently. Trends in the field, including greater focus on internally displaced persons and those living in non-camp settings, as well as refugees in camps, the protracted nature of emergencies, and an increasing need for empirical evidence, will influence future progress. Résumé Les troubles politiques et civils dans les pays à faibles ressources soulignent le besoin de services spécialisés de santé génésique pour les personnes déplacées. Les femmes déplacées souffrent en particulier d’une mortalité maternelle élevée, de besoins insatisfaits de planification familiale, des complications d’avortements non médicalisés et de la violence sexiste, ainsi que d’IST, notamment le VIH. Les institutions d’aide humanitaire et de développement et les Nations Unies ont préparé du matériel technique et introduit des changements politiques positifs dans les environnements de crise et elles s’efforcent d’améliorer les soins de santé génésique. Des manques importants n’en demeurent pas moins. La collaboration pendant les crises est bonne, beaucoup d’institutions travaillant dans un ou plusieurs réseaux. L’initiative quinquennale RAISE rassemble les principales institutions des Nations Unies et ONG spécialisées dans l’aide humanitaire et le développement, et se fonde sur leur expérience pour soutenir la prestation de services, le plaidoyer, la formation clinique et la recherche en santé génésique. Ces organisations ont accepté d’utiliser des directives communes, de définir conjointement les priorités et de partager les ressources, permettant ainsi de mener des opérations plus harmonieuses et de réduire le nombre d’activités qui se chevauchent. Les progrès futurs seront influencés par les tendances dans ce domaine, notamment la priorité accrue accordée aux personnes déplacées à l’intérieur de leur pays et qui vivent hors des camps, en plus des réfugiés des camps, la durée prolongée des urgences et le besoin croissant de données empiriques. Resumen El continuo descontento político y civil en países con pocos recursos recalca la necesidad continua de proporcionar servicios especializados en salud reproductiva para personas desplazadas. Las mujeres desplazadas en particular afrontan una alta tasa de mortalidad materna, necesidad insatisfecha de planificación familiar, complicaciones después del aborto inseguro y violencia basada en género, así como enfermedades de transmisión sexual, incluido el VIH. Las organizaciones de socorro y desarrollo y organismos de la ONU han elaborado materiales técnicos, realizado cambios positivos a las políticas, específicos a los ámbitos de crisis, y están trabajando para proporcionar mejores servicios de salud reproductiva. Sin embargo, aún existen importantes brechas. La colaboración en el campo de la salud reproductiva en crisis es notable, ya que muchos organismos trabajan en una o más redes. La Iniciativa RAISE de cinco años reúne importantes organismos de la ONU y ONG de los campos de socorro y desarrollo, y se basa en su experiencia para apoyar la prestación de servicios de salud reproductiva, actividades de promoción y defensa, capacitación clínica e investigación. La buena disposición para utilizar documentos de orientación en común, determinar prioridades conjuntamente y compartir recursos ha propiciado mejores actividades y menos traslapo que si cada organismo hubiera trabajado independientemente. Futuros avances serán influenciados por las tendencias en el campo, como un mayor enfoque en las personas desplazadas internamente, aquéllas fuera de los campamentos y los refugiados en los campamentos, la prolongada naturaleza de las urgencias y la creciente necesidad de evidencia empírica.
Article
Based on articles found on the PubMed and Popline databases on the provision of first-trimester abortion by mid-level providers, this article describes policies on type of abortion provider, comparative studies of different types of abortion provider, provider perspectives, and programmatic experience in Bangladesh, Cambodia, France, Mozambique, South Africa, Sweden, the United States of America and Viet Nam. It shows that it is safe and beneficial for suitably trained mid-level health-care providers, including nurses, midwives and other non-physician clinicians, to provide first-trimester vacuum aspiration and medical abortions. Moreover, it finds that projects in Kenya, Myanmar and Uganda have successfully trained nurse-midwives to provide post-abortion care for incomplete abortion with manual vacuum aspiration, and that studies in Ethiopia and India have recommended that providers such as auxiliary nurse-midwives should be trained in abortion service delivery to ensure that they provide safe abortions for low-income women. The paper recommends the authorization of all qualified mid-level health-care providers to carry out first-trimester abortions, and it also recommends the integration of training in providing first-trimester abortion care into basic education and clinical training for all mid-level providers and medical students interested in obstetrics and gynaecology. Finally, it calls for documentation of the role of mid-level providers in managing second-trimester medical abortions to further inform policy and practice.
Article
Deaths resulting from unsafe induced abortions represent a major component of maternal mortality in countries with restrictive abortion laws. Delays in obtaining care for maternal complications constitute a known determinant of a woman's risk of death. However, data on the role of delays in providing care at health care facilities are sparse. The association between the cause of maternal death (abortion versus post-partum haemorrhage or eclampsia) and the time interval between admission to hospital and the initiation of treatment were evaluated among women who died at the Maternité du Centre Hospitalier de Libreville, Gabon, between 1 January 2005 and 31 December 2007. The women's characteristics and the time between diagnosis of the condition that led to death and the initiation of treatment were compared for each cause of death. After controlling for selected variables, the mean time between admission and treatment was 1.2 hours (95% CI: 0.0-5.6) in the case of women who died from post-partum haemorrhage or eclampsia and 23.7 hours (95% CI: 21.1-26.3) in the case of women who died of abortion-related complications. In conclusion, delay in initiating care was far greater in cases of women with complications of unsafe abortion compared to other pregnancy-related complications. Such delays may constitute an important determinant of the risk of death in women with abortion-related complications.
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J Kinaro et al / Reproductive Health Matters 2009;17(34):71-77
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