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Abortion-related complications in Cambodia
T Fetters,aS Vonthanak,bC Picardo,cT Rathavyd
aResearch Evaluation, Ipas, Chapel Hill, NC, USA bNational Institute of Public Health and National Centre for HIV/AIDS, Phnom Penh, Cambodia
cDepartment of Social Medicine, University of North Carolina, Chapel Hill, NC, USA dMaternal and Child Health Programme, Phnom Penh,
Cambodia
Correspondence: T Fetters, Ipas, 300 Market Street, Suite 200, Chapel Hill, NC, USA. Email fetterst@ipas.org
Accepted 20 March 2008.
Introduction Although termination of pregnancy (termination)
has been legal in the Kingdom of Cambodia since 1997, a number
of barriers to safe termination services persist and many women
continue to induce their own terminations or seek unsafe services
that result in complications requiring ‘post-abortion’ care.
Objective To describe the complications of miscarriage and failed
terminations and document the magnitude of the resulting
morbidity in the Cambodian public sector.
Design Cross-sectional descriptive study.
Setting Public sector hospitals and health centres.
Sample Stratified multistage sampling design included all hospitals
(n= 71), 14% of eligible high-level health centres (n= 58) and
22% of eligible low-level health centres (n= 57).
Methods Data collectors used a standardised questionnaire to record
information on diagnosis, reproductive history and treatment from
629 women seeking care for termination or miscarriage-related
complications in study facilities over a 3-week period.
Main outcome measures Annual estimate of cases, clinical
symptoms, severity distribution of morbidity, ratio of
complications to live births and incidence of abortion
complications for Cambodian public health facilities.
Results In 2005, an estimated 31 579 women with complications
of miscarriage or terminations were treated in Cambodian
government facilities; 80% of these women sought care at a health
centre. Forty percent of all women seeking care for complications
either reported or showed strong clinical evidence of prior
attempted terminations. Nearly 17% of these women were in the
second trimester of pregnancy and 42% of them presented with
high severity complications. The annual incidence of termination
and miscarriage complications (abortion complications) was 867
per 100 000 women of reproductive age. The projected ratio of
complications was 93 per 1000 live births.
Conclusions To reduce maternal morbidity in Cambodia, women
must be encouraged to seek safe termination services or seek
postabortion care without delay. Additionally, providers need
further training, and facilities greater commitment, to provide safe
terminations and care for complications of unsafe terminations
and miscarriage.
Keywords Abortion, post-abortion care, Cambodia.
Please cite this paper as: Fetters T, Vonthanak S, Picardo C, Rathavy T. Abortion-related complications in Cambodia. BJOG 2008;115:957–968.
Introduction
Cambodia has one of the most dire maternal health situations
in Asia. Since the early 1990s, the nation has struggled to
rebuild the public health infrastructure, train new health
personnel and renew confidence in government health serv-
ices destroyed by years of war and genocidal policies. At 472
maternal deaths for every 100 000 live births, the country’s
maternal mortality ratio is second only to that of Laos (in
South-East Asia), ten times higher than neighbouring Thai-
land and three times higher than Vietnam. Although modern
contraceptive use has risen in the past two decades, accep-
tance remains comparatively low for Asia: only 27% of married
women use modern methods compared with 79 and 60%,
respectively, of married women in Vietnam and Indonesia.1–3
Significant disparity persists between urban and rural women
in contraceptive use and fertility. Fertility is lowest in Phnom
Penh (at 2.5 children per woman), while remaining much
higher in rural provinces where women in late childbearing
years have an average of 5.2 children.1Consequently, between
2000 and 2005, 28% of all births were either unwanted or
mistimed.1
Unsafe abortion, or unsafe termination of pregnancy, is
known to be a major contributor to maternal mortality and
poor maternal health. The World Health Organization (WHO)
estimates that unsafe terminations account for 13% of global
pregnancy-related deaths,4nearly all of which can be pre-
vented with appropriate training, technology and equitable
access to safe termination services. The Cambodian Penal
Code was revised in 1997 to allow termination on request
ª2008 Ipas Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 957
DOI: 10.1111/j.1471-0528.2008.01765.x
www.blackwellpublishing.com/bjog Epidemiology
through the 12th week of pregnancy and limited access in the
second trimester.5However, provider reluctance to begin ter-
mination services in public facilities, unregulated and erratic
fees for termination, slow adoption of technical guidance and
provider training in high-quality termination services and
women’s fears of mistreatment by providers all continue to
create barriers to safe terminations.6–9
Fuelled by a burgeoning post-war private sector, an in-
creasing demand for education among men and women,
and a lack of available and acceptable options for fertility
control, a largely unregulated economy for terminations has
flourished in Cambodia in recent years.8,9 The 1997 legal-
isation of terminations paved the way for the expansion of
quasi-legal termination services as the country began their
demographic transition from high to medium fertility, a time
of great demand for smaller families. Close proximity to Viet-
nam, which has one of the world’s highest rates of termina-
tion, has provided a group of lay midwives and an informal
training ground for healthcare providers interested in pro-
viding termination services.8,9 Today, Cambodian women
seek care for unintended pregnancies from both skilled and
unskilled healthcare providers, herbalists, drug sellers and all
types of traditional medical practitioners. Many of these
women will experience complications and seek further post-
abortion care (PAC) in government and private health facil-
ities. Descriptive studies in Latin America, Asia, Nigeria and
Uganda estimate that this percentage is between 15 and 28%
of all women who obtain an unsafe termination, depending
largely on accessibility, hospital policies, quality of care and
the efficacy and invasiveness of the unsafe termination pro-
cedures predominant in the country at a particular time.10–14
In this study, we provide information from a context where
termination should be safe and legal, but a lack of regulation
and weak implementation of the law has prohibited equi-
table and widespread access to these services. The goal of this
study was to describe treatment of complications, both from
attempted termination and miscarriages (spontaneous abor-
tions), and document the magnitude of attempted termina-
tion and miscarriage-related morbidity in the Cambodian
public health service. An estimate of the annual incidence of
all termination and miscarriage (abortion) morbidity and the
projected ratio of all related complications in Cambodia’s
public sector facilities articulate the scope of these govern-
ment services in relation to the population. Care seeking for
complications in hospitals and health centres and documen-
tation of the severity of women’s symptoms have been explored
for all women seeking termination-related care. Women’s
own reports of attempted termination are combined with
clinical evidence of reported unsafe termination attempts
to use as a measure of complications related to unsafe termi-
nations. This study is the first national study of its kind
in Cambodia and the first to be conducted in Asia. Data on
the incidence of and morbidity due to complications from
attempted terminations and miscarriages will be used as a
baseline for national PAC and safe termination programmes
as these services are improved and expanded throughout the
nation.
Data and methods
Facility sample
The study was conducted in 100% of Cambodia’s public hos-
pitals (n= 71) with obstetrics and delivery services and in
a nationally representative sample of 115 health centres. The
sampling strategy is detailed in Figure 1. According to health
facility and administrative data collected by the National
Institute of Statistics in 2003, the Kingdom of Cambodia
maintained 1022 health facilities nationwide (86 hospitals,
887 health centres and 49 health posts).15 Using this sampling
frame, a total of 256 sites did not meet the inclusion criteria of
having a midwife or a physician on staff, offering maternity
services and offering the Government’s Minimum Package of
Activities (MPA).16 The sites that were ineligible for the study
included all 49 health posts, 15 hospitals that did not provide
obstetric services, and 192 health centres that had no building,
did not employ a full-time midwife or physician, did not offer
the MPA or did not offer maternity services. The inclusion
criteria were met by 695 health centres and 71 hospitals.
A stratified multistage sampling design was used for selec-
tion of health centres. First, health centres were categorised
into two groups based on the Ministry of Health regulations
governing their capacity and expectations to provide termi-
nation and PAC services: (1) high-level health centres with
a full-time physician or secondary midwife (n= 416) and (2)
low-level health centres with only a primary midwife (n=
279), not allowed by the national guidelines to provide uter-
ine evacuations and expected only to stabilise and refer
women to another facility. (A primary midwife is sanctioned
to perform a limited scope of maternal health care, while
a secondary midwife has a more comprehensive set of skills
and is allowed to provide life-saving obstetric care, PAC and
early terminations.) High-level health centres have 0–90 beds
and are expected to provide some PAC services, low-level
health facilities are smaller and more rural, 0–40 beds, and
are expected only to stabilise women with complications from
miscarriage and attempted terminations and refer them to
a referral hospital. Health centres were chosen from the strata
using probability proportionate to size (PPS) sampling based
on the number of beds in the facility; for example, larger
health centres with more beds had a higher probability of
being selected into the sample. A total of 68 high-level and
64 low-level health centres were randomly selected as data
collection sites using SAS version 8.0.
After selection for participation, ten high-level and seven
low-level health centres were dropped from the study because
either facilities were too difficult to reach (n= 7), providers
Fetters et al.
958 ª2008 Ipas Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
did not attend data collection training (n= 8) or the provider
could not or did not return to work after training (n= 2).
Excluded health centres were not replaced; rather they were
treated as nonresponses and appropriately adjusted for in the
final weighted analyses. Ultimately, all eligible hospitals (n=
71), 14% of all eligible high-level health centres (n= 58) and
20% of all eligible low-level health centres (n= 57) were
included in the study.
Data collection
In June–July of 2005, study coordinators from the National
Reproductive Health Programme and the National Institute
of Public Health (NIPH) requested that maternal health offi-
cers in charge of termination or PAC services from each study
facility attend one of four 2-day training sessions. After train-
ing, each healthcare provider returned to his or her health
facility and recorded information over a period of 21 consec-
utive days in a standardised data capture form on all requests
for termination and all cases of complications requiring fur-
ther care (WHO International Classification of Disease clin-
ical diagnoses of incomplete, missed, inevitable, complete,
spontaneous and septic abortion) of less than 22 weeks of
gestation.1The form was prepared in English, translated into
Khmer and pre-tested. Cases of ectopic pregnancy or threat-
ened abortion were excluded from the study. Data capture
forms contained questions associated with standard patient
demographics and reproductive history, symptoms that drew
the woman to the facility, clinical management and costs of
care. The flow of the data capture form approximated the
continuum of care to facilitate efficient completion during
or immediately following the woman’s care.
Providers were not asked to distinguish between a miscarri-
age and an attempted termination but were asked to note any
physical evidence of attempted termination on each woman’s
examination. The clinicians were also instructed to ask women
if they had ‘done anything to induce this abortion’ as part of
the routine case history taken on admission.
Data were collected over 21 consecutive days during a
5-week period in July–August 2005. Six data collectors super-
vised the data collecting providers. Each site was visited at
least once during the data collection period; supervisors also
maintained telephone contact wherever possible. Providers
were personally remunerated for participation and facilities
received a thermometer and blood pressure cuff. After
weighting, case information recorded in these facilities repre-
sent the national public sector cases of ‘abortion complica-
tions’ during the study period and, after multiplying by the
number of 21-day periods in a calendar year, represent the
annual cases managed in Cambodia’s public sector.
The study protocol was reviewed and approved by the
National Ethics Committee for Health Research for the King-
dom of Cambodia. Client names were recorded on the first
Figure 1. Sampling strategy of national public sector hospitals and health centres.
Abortion complications in Cambodia
ª2008 Ipas Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 959
page of the questionnaire until the supervisor verified the case
and checked for completeness; identifying information was
then removed from the questionnaire and destroyed.
Data analysis
This study applied a methodology similar to other studies
using the symptoms of complications from miscarriage or
attempted terminations to assess abortion morbidity, case
fatality and mortality on a national scale.17–23 The methodology
was first proposed by a Task Force of the WHO for determi-
nation of spontaneous and unsafe abortions.24 The clinical
criteria were later tested and adapted by researchers in South
Africa who proposed using only women’s symptoms, as
observed by their providers, to categorise low, moderate
and high severity complications (Table 1).18 The methodol-
ogy has been used to classify cases using a retrospective med-
ical record review10,11,25 and for prospective use by researchers
in South Africa,17–22 Kenya23 and now in Cambodia. In South
Africa, the study was conducted twice in a 4-year period to
document changes in abortion-related morbidity due to legal-
isation of terminations in the country.19,22
In this study, a combination of observed symptoms and
women’s self-reports of unsafe terminations have been used
to identify a subset of women who had attempted a termina-
tion outside of a recognised facility. This group of women
either told the healthcare provider that they had ‘already done
something to terminate their pregnancies’ or showed strong
clinical evidence of such limited to vaginal evidence of miso-
prostol, evidence of a foreign body or mechanical injury to the
vaginal or cervical area. All women with ‘evidence of foreign
body in the vaginal or cervical area’ were validated after data
collection with the provider.
A woman who has an unsafe termination, a miscarriage or
even a safely performed termination (in rare instances) may
suffer from complications. Some women will not seek care,
while others may seek care for mild symptoms or to ensure
that the miscarriage or termination is complete. In determin-
ing severity, women in the low severity category had no
adverse or suspicious symptoms other than bleeding. The
classification of highly severe cases was conservatively applied
and, in some cases, verified with the healthcare providers. All
women with a high pulse rate had an additional high severity
factor. Thus, all highly severe cases were the result of elevated
temperatures, organ failure, shock, death and/or evidence of
a foreign body or mechanical injury to the vaginal or cervical
area.
Data were entered twice and checked for consistency and
completeness at the NIPH in Phnom Penh, using EpiData
version 6.0, then imported into SAS 8.0 and Stata 9.1 for
further analysis at Ipas, NC, USA. Information on 674 cases
was recorded during the study period. Data from 45 cases
were excluded because gestational age was either missing
(n= 33) or greater than 21 weeks (n= 12; Table 2). There
was no association between case exclusion and type of facility.
Forty-two women were missing one or more variables needed
to classify severity of their cases. Most of the missing data was
for a lack of any indication regarding the possibility of a foreign
body inserted in the uterus, vagina or cervix or mechanical
injury to the same areas. Severity was imputed by randomly
assigning severity level to missing cases at the same proportion
as observed in the non-missing cases grouped by low/elevated
temperature and gestational age <13/13–21 weeks.
Methods of variance estimation for survey data were used
to account for the complex sample design (stratified PPS
sampling). Specifically, standard errors (SEs) were obtained
using the Taylor-series approximation. Weighted data were
used in bivariate analysis, which included chi-square test for
categorical variables and analysis of variance for continuous
variables. Statistical significance was defined a priori as <0.05.
The ‘national rate of abortion complications’ in the public
sector and the ‘national abortion ratio’ were estimated using
the weighted study findings and Cambodia population esti-
mates from the most recent national census (1998), specifi-
cally, a population estimate of 3 644 327 women aged 15–49
years who produced 340 470 live births during 2005.26
Results
A total of 629 cases of complications from miscarriages and
terminations were eligible for analysis (Table 3). After adjust-
ment for sampling design, the largest health centres accounted
for 61% (95% CI 53–70) of the cases seen in the public sector,
while the remaining cases were encountered in similar pro-
portions in the hospitals (17%, 95% CI 13–22) and low-level
health centres (21%, 95% CI 16–29). More than one-third of
Table 1. Clinical typology for classification of severity of
complications after termination or miscarriage*
Low (requires all criteria) Temperature ,37.3C
No clinical signs of infection
No system or organ failure
No suspicious findings on evacuation
Moderate (requires one or
more criteria)
Temperature 37.3–37.9C
Localised peritonitis (tender uterus
and discharge)
Offensive products of conception
High (requires one or
more criteria)
Death
Shock
Evidence of foreign body or
mechanical injury
Temperature .37.9C
Organ or system failure
Pulse .119 beats/minute
Generalised peritonitis
*Adopted from Rees et al.17
Fetters et al.
960 ª2008 Ipas Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
all women (35%, 95% CI 24–49) were referred to other health
facilities for further treatment.
Women in the sample ranged from 16 to 53 years of age,
with a mean age of 31.8 years (SE 0.35) and had 0–10 prior
births (median 3, Table 3). More than one-third of the sample
reported using contraception at the time of conception (38%,
95% CI 31–45), and a similar proportion stated they had
attempted to terminate the pregnancy before presenting for
treatment (37%, 95% CI 29–47). Of the women who reported
an attempted termination outside of a recognised facility, 48%
reported contraceptive use (95% CI 38–57). The mean clinical
estimation of gestational age was 9.8 weeks based on bimanual
examination. Most women (83%, 95% CI 75–89) presented
for treatment during the first trimester of pregnancy, but 17%
(95% CI 11–25%) presented in the second trimester (13 or
more completed weeks). No statistically significant difference
in age, contraceptive use, acknowledgement of attempted ter-
mination or length of gestation was found among the women
seeking care at the three types of health facilities.
Among women treated at the three types of health facilities,
the severity of complications from miscarriages and termina-
tions differed somewhat (P= 0.07). A higher proportion of
low severity cases were seen at hospitals, while the health
centres encountered higher proportions of women with high
severity complications. In the health centres overall, women
presented with high severity complications more frequently
than with low or moderate complications.
More than one-third of the 629 women with complications
from miscarriages and terminations presented with a temper-
ature ‡38C (36%, 95% CI 28–44) (Table 4). Although not
achieving statistical significance, the percentage of cases with
elevated temperatures was higher in the health centres than in
the hospitals (P= 0.09). Only 2% of all women had an ele-
vated pulse rate of greater than or equal to 120 beats per
minute. Further clinical estimation of complications was cat-
egorised by signs of infection, signs of organ failure and/or
suspicious findings upon evacuation of the uterus. There were
no diagnoses of generalised peritonitis or tetanus among the
women in the study (data not shown). Three-quarters of all
women presented for care with no signs of infection. There
were significantly fewer women with a tender uterus noted on
examination among women seen in the lowest level health
centres (P= 0.04). Women presenting with signs of serious
infection or organ failure were unusual, the most common
being septic shock/sepsis and disseminated intravascular coa-
gulopathy. These women were encountered primarily in the
hospital setting. Women in septic shock were more likely to
present at hospitals (P< 0.01). Most women with bowel
injury and uterine perforation were also seen at hospitals.
Only one maternal death occurred in a hospital during the
study period; therefore, national estimates of abortion-related
maternal mortality could not be reliably made.
Signs of mechanical injury to the genitalia were statistically
more likely to be noted on examinations of women at hospitals
and at low-level health centres (P= 0.03). Physical evidence of
attempted termination, such as the presence of misoprostol,
mechanical injury to the vaginal or intra-abdominal area or
a foreign body noted on vaginal examination, was recorded
for 8% of women presenting for treatment (Table 3). The
distribution of these findings was similar among the health-
care settings. ‘Offensive’ products of conception, products
that were retained or showing other signs of infection, were
noted in almost one-third of cases in all facilities (31%, 95%
CI 24–40). There were no statistically significant differences in
cases with offensive products by facility type.
The severity of a woman’s complications was not signifi-
cantly associated with whether she had attempted an induced
abortion, based on clinical examination, and/or patient dis-
closure (P= 0.36, Table 3). After adjusting for sampling, 40%
of all women either self-reported an attempted termination
outside of a recognised facility (38%) or showed strong clin-
ical evidence of a foreign body, mechanical injury or undis-
solved misoprostol inserted vaginally (6%) or both (3%).
Relative to all severity groups, slightly more women in the
low severity group (45%, 95% CI 33–58) showed clinical
evidence of an unsafe termination or self-reported having
attempted to induce the termination before ultimately seek-
ing care for complications. A similar proportion, 40% (95%
CI 30–52), of women among the severe cases either reported
or showed clinical evidence of an attempted termination.
Based on the number of cases of complications from miscar-
riages and attempted terminations recorded during the 21-day
Table 2. Comparison of excluded cases and reasons by site, unweighted (n=674)
Hospitals
(unweighted, n5343)
High-level HC
(unweighted, n5220)
Low-level HC
(unweighted, n5111)
Excluded cases (n545)
.21 weeks 10 2 0
Missing gestational age 23 3 7
Imputed cases (n542)
Missing information necessary to classify severity 7 21 14
HC, health centres.
Abortion complications in Cambodia
ª2008 Ipas Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 961
study period, projections of the annual total number of cases in
the public facilities may be estimated, taking into account
adjusted sampling weights and design effects. Based on these
projections, 31 579 women with ‘abortion complications’ are
treated annually in government health facilities (Table 4). Sev-
enteen percent of cases, or 5222 women (95% CI 2794–7650),
Table 3. Case characteristics, clinical symptoms and management outcome by type of facility for complications of miscarriage and terminations
(unweighted, n=629)
Total
(n5629)
Hospital
(n5310)
HC high
(n5215)
HC low
(n5104)
Pvalue*
Age, in years
Mean (95% CI) 31.8 (31.1–32.5) 31.5 (30.5–32.6) 31.7 (30.8–32.6) 32.4 (30.6–34.2) 0.725
Parity
Median (95% CI) 3 (0–10) 2 (0–10) 3 (0–10) 3 (0–9) —
% (95% CI)** % (95% CI)** % (95% CI)** % (95% CI)**
Reported use of modern contraception
at time of conception
38 (31–45) 32 (26–39) 38 (29–48) 41 (28–56) 0.554
Reported termination attempt 37 (29–47) 42 (36–48) 38 (26–53) 31 (18–48) 0.557
Gestational age (weeks)
,13 83 (75–89) 72 (65–78) 85 (70–93) 89 (79–95) 0.110
13–21 17 (11–25) 28 (22–35) 15 (7–30) 11 (5–21)
Severity status
Low 28 (22–35) 42 (33–52) 23 (15–32) 32 (21–45) 0.071
Moderate 30 (23–37) 28 (22–35) 31 (22–43) 26 (16–38)
High 42 (35–50) 30 (23–37) 46 (35–57) 42 (31–54)
Temperature (C)
,37.3 39 (31–49) 58 (50–66) 35 (23–50) 37 (26–50) 0.089
37.3–37.9 25 (19–32) 20 (15–26) 25 (16–37) 27 (17–39)
38 36 (28–44) 22 (17–28) 39 (28–52) 36 (26–47)
Pulse
120 beats per minute 2 (1–5) 3 (1–5) 2 (1–6) 4 (1–11) 0.568
Signs of infection
No signs of infection 75 (66–82) 71 (62–78) 73 (60–83) 83 (69–91) 0.355
Offensive discharge 18 (12–26) 21 (15–30) 17 (9–30) 17 (9–30) 0.787
Tender uterus 13 (7–23) 14 (9–21) 17 (8–33) 3 (1–10) 0.038
Septicaemic shock/sepsis 1 (,1–1) 3 (1–7) ,1(,1–1) 0 ,0.001
Other (bowel injury, uterine perforation and
pelvic abscess)
1(,1–2) 2 (1–4) ,1(,1–3) 0 0.272
Localised peritonitis ,1(,1–1) 1 (,1–3) 0 0 0.326
Signs of organ failure
No signs of organ failure 96 (93–98) 92 (87–96) 96 (90–99) 98 (94–100) 0.135
Disseminated intravascular coagulation 2 (1–6) 5 (3–9) 2 (1–9) 0 0.233
Hypovolaemic shock 1 (,1–2) 1 (,1–3) 1 (,1–3) 2 (,1–6) 0.676
Renal failure ,1(,1–2) 1 (,1–3) ,1(,1–3) 0 0.363
Other (respiratory distress syndrome, central
nervous system failure and liver failure)
1 (1–3) 3 (1–8) 1 (,1–3) 1 (,1–6) 0.418
Death ,1(,1to,1) ,1(,1–2) 0 0 0.593
Findings on evacuation
Offensive products of conception 31 (24–40) 29 (22–37) 35 (24–48) 22 (13–35) 0.212
Evidence of misoprostol 3 (2–6) 7 (4–12) 2 (1–5) 4 (2–11) 0.076
Mechanical injury to vagina, cervix, uterus or
intra-abdominal
3 (2–4) 5 (3–9) 1 (,1–4) 5 (2–10) 0.030
Foreign body 2 (1–5) 3 (1–11) 1 (,1–5) 3 (,1–21) 0.382
HC, health centres. Bold text indicates a finding that is statistically significant at the alpha ,0.05 level.
*Reported Pvalues are associated with x2tests of association for categorical variables and t-tests for continuous variables.
**All percentages and associated 95% CIs have been adjusted for the survey design using weighting.
Fetters et al.
962 ª2008 Ipas Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
are in the second trimester of pregnancy when they present for
care and 13 379 (42%) are high severity complications.
The annual incidence of ‘abortion complications’ in public
sector facilities is 867 per 100 000 women of reproductive
age (Table 5). Although there were fewer maternal deaths in
Cambodia than in Kenya, where similar research has been
conducted, women in this study had a much higher propor-
tion of high severity complications. Of the projected cases in
Cambodia, 2.4 per 1000 (95% CI 1.7–3.1 per 1000) will pres-
ent with low severity complications, 2.6 per 1000 (95% CI
1.8–3.4 per 1000) with moderate severity complications and
3.7 per 1000 (95% CI 2.7–3.6 per 1000) with high severity
complications. The projected ratio of complications from
miscarriages and attempted terminations to live births is 93.
The annual case fatality rate for these complications in gov-
ernment facilities is estimated to be low, only 0.06%.
Discussion
The population observed during the study period was an
older population compared with similar studies conducted
elsewhere. No woman was younger than 16 years and the
mean age of women presenting for treatment was 31.8 years.
On average, these women had already been pregnant three
times. One-third of the women seeking care reported using
modern contraception at the time they became pregnant. This
proportion is slightly higher than national contraceptive use
reported in the 2005 Cambodia Demographic and Health
Survey (CDHS),1in which 27% of married women reported
using a modern method of family planning. Sixty-seven per-
cent of women in the study did not want to become pregnant
in the next several months. The majority cited use of methods,
such as oral contraception, condoms or injectable contracep-
tives. Of the women who reported trying to terminate their
pregnancies, more than half, 53%, reported that the preg-
nancy was a result of a contraceptive failure.
For a woman who is determined to end an unintended
pregnancy, an early termination is safer.27 Increased gesta-
tional age is a predictor of increased procedural risk,28 par-
ticularly in Cambodia where second-trimester services are
limited and providers continue to use outdated technology
and procedures.29 Seventeen percent of the women treated in
this study were beyond the first trimester of pregnancy. As
miscarriage is uncommon in the second trimester,28 these
women are likely to have had terminations by unsafe pro-
cedures, which further increased their risks. In Kenya,
researchers found that second-trimester complications, which
accounted for over one-third of all cases, had higher odds of
being in the moderate or severe categories than first-trimester
cases.
Relatively little is known about healthcare seeking behav-
iours of Cambodians. Some research has documented a lack of
confidence in the public sector, particularly at the health cen-
tre level, where facilities are notoriously understaffed.30,31
However, for many women, location is the most important
factor in emergency care. According to the CDHS, rural and
urban residents who chose to seek care in the public sector
most often used health centres.1Despite our prediction that
women with more serious complications from miscarriage
and attempted terminations would seek care in hospitals,
the opposite occurred. Women who presented for care at
hospitals were more often suffering from low severity compli-
cations, while women at both levels of health centre were more
often high severity (P= 0.071), seeking care in facilities with
the least capacity to manage their cases. The exception to this
trend was among women who had been pregnant longer;
women in their second trimester of pregnancy more often
sought care at hospitals (P= 0.110). In addition, women
treated in health centres were likely to be older, to report using
contraception and to have more children, but they were less
likely to report an attempted termination before seeking care.
None of these differences achieved statistical significance.
Table 4. Projected annual total number of cases of complications from miscarriage and terminations treated in the public sector by severity
category and facility type
Total
(n531 579)
(95% CI 25 227–37 931)
Hospital
(n55388)
(95% CI 4406–6369)
HC high
(n519 413)
(95% CI 13 464–25 361)
HC low
(n56778)
(95% CI 4778–8779)
Gestational age
First-trimester complications 26 357 (20 444–32 270) 3876 (3101–4651) 16 431 (10 841–22 021) 6049 (3999–8100)
Second-trimester complications 5222 (2794–7650) 1512 (1051–1973) 2982 (606–5357) 729 (257–1201)
Severity
Low severity complications 8867 (6327–11 405) 2277 (1475–3079) 4412 (2224–6600) 2177 (1076–3279)
Moderate severity complications 9333 (6368–12 299) 1512 (1111–1913) 6082 (3341–8917) 1739 (809–2670)
High severity complications 13 379 (9776–16 983) 1599 (1243–1955) 8919 (5462–12 375) 2862 (1714–4009)
HC, health centres.
Abortion complications in Cambodia
ª2008 Ipas Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 963
It is not possible to determine with certainty why this
occurred. This pattern of morbidity may be the result of in-
equitable access to treatment, with women in less densely
populated rural areas seeking care later or perhaps seeking
care in the informal system and delaying their entrance to
public hospitals. Women in more densely populated urban
and peri-urban areas around hospitals may seek care sooner
because they have better information on services, transporta-
tion and funds to access a hospital. Women seeking care in
health centres may be underestimating the severity of their
symptoms and subsequently the need for medical attention.
Although they may pay dearly, Cambodians are more likely
to seek health care in the private sector, where 37% of pre-
vious terminations took place rather than in the public sector
where only 11% of terminations were reported to have
occurred.1,30 In a 1998 study on health care seeking cost and
behaviours, 60% of women who had delivered did not choose
public facilities as their preferred location for delivery, stating
reasons, such as distance, cost, lack of drugs and inconsistency
in keeping with Khmer tradition.31 Despite the legality of
termination, many women attempted terminations at home
or in unauthorised facilities before seeking PAC. Of these,
nearly 40% went to drug sellers, a common source of health-
care information and medication. Although oral misoprostol
administration was probably used in some cases, only 3% of
women presented with vaginal evidence of the drug, a gastric
ulcer medication available and well known for inducing uter-
ine contractions. It is possible that women using misoprostol
consulted with a healthcare provider to determine the correct
regimen, but we did not request this information. Seeking
care or information from a non-medical professional or even
at a nearby health centre may be a necessity for many women,
but misinformation is probably responsible for at least a part
of the high level of morbidity seen in this study.
After combining all women with strong clinical evidence of
an attempted termination (vaginal evidence of misoprostol,
mechanical injury or presence of a foreign body) with women
who reported terminations at home or outside of an author-
ised facility, more than one-third (40%) of women showed
strong clinical evidence or reported a termination attempt
prior to seeking PAC services in the government sector. It is
likely that the terminations women received before presenting
to the public facilities in the study were ‘unsafe’ or ‘proce-
dures for terminating an unwanted pregnancy either by per-
sons lacking the necessary skills or in an environment lacking
the minimal medical standards, or both’.4This finding is
consistent with Demographic and Health Survey (DHS) find-
ings in which 45% of Cambodian women who reported hav-
ing a termination in the past 5 years told interviewers that
they had performed so in a home rather than a health facility.1
Table 5. Selected contextual variables and results of the South Africa, Kenya and Cambodia ‘facility-based abortion morbidity and
mortality’ studies
South Africa 200019 Kenya 200223 Cambodia 2005
Legal indications for termination On request through 12 weeks.
Some restrictions after
12 weeks
Legal only to save the
life of the woman
On request through 12 weeks.
Some restrictions after
12 weeks
Women of reproductive age (WRA)* 13 478 000 6 895 000 3 644 327**
Total births 1 106 000 1 088 102 340 470**
Maternal mortality ratio 340 414*** 472****
No. of hospitals included 47 143 71
No. of health centres included 0 0 115
Data collection period (days) 21 21 21
Low severity cases (%) 72.4 55.8 28
Moderate severity cases (%) 17.9 16.3 30
High severity cases (%) 9.7 27.9 42
Maternal deaths 1 7 1
Projected annual cases of ‘abortion complications’ 49 653 20 893 31 579
Annual incidence of ‘abortion complications’ 362/100 000 WRA 303/100 000 WRA 867/100 000 WRA
Ratio of ‘abortion complications’ 44/1000 live births 19/1000 live births 93/1000 live births
Case fatality rate (%) Not presented 0.87 0.06
*Republic of South Africa WRA 512–49 years and Kenya and Cambodia WRA 515–49 years.
**International database of the US Census Bureau [www.census.gov/cgi-bin/ipc/idbagg].26
***Central Bureau of Statistics (CBS) (Kenya), Ministry of Health (MOH) (Kenya) and ORC Macro. Kenya Demographic and Health Survey 2003.
Calverton, MD: CBS, MOH, and ORC Macro, 2004.
****National Institute of Public Health, National Institute of Statistics [Cambodia] and ORC Macro.1
Fetters et al.
964 ª2008 Ipas Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
Four of ten women reporting or showing evidence of prior
induction attempts presented with severe complications.
Unsafe terminations affected women regardless of healthcare
setting, underscoring that unsafe termination is not strictly
a rural or urban phenomenon.
Only one death due to abortion-related complications was
recorded during the study period. Women seen at hospitals
and high-level health centres were among the most medically
complicated (e.g. presenting with organ failure or perfora-
tions); yet, we cannot be certain that all the most serious cases
ever made it to hospitals or clinics, given the remoteness of
some Cambodian villages.
Table 5 highlights some important differences in the results
of three of the studies using this methodology.17–23 The
Cambodian and South African laws are similar in content
and legality for termination of pregnancy; however, the Kenyan
law is much more restrictive, allowing women to have termi-
nations only to save their lives. The annual incidence of ‘abor-
tion complications’ (892/100 000 women of reproductive
age) and the ratio of complications from miscarriages and
attempted terminations (87/1000 live births) were highest in
Cambodia compared with South Africa and Kenya. Higher
figures reported in Cambodia can be partially attributed to
the inclusion of health centres and poorer access to hospitals
in these areas, whereas the South African and Kenyan studies
only collected data in hospitals. After adjustment for sam-
pling, Cambodian health centres contributed just more than
80% of the cases. Mortality was highest in Kenya. The number
of hospital deaths in Kenya was higher than those found in
both South Africa and Cambodia where only one death was
reported in each country, resulting in a higher case fatality
rate in Kenya.
Researchers in South Africa have found that mortality lev-
els and severe morbidity have decreased after introduction of
legal termination in that country in 1996.19,22 Overall, in
South Africa, researchers did not find fewer cases of abortion
complications between 1994 and 2000, but they report that
the severity of the complications diminished. Authors in
South Africa propose that this change is likely the result of
increased community awareness, use of manual vacuum aspi-
ration and use of misoprostol.19–22,32
The use of pharmaceuticals from neighbouring countries
and/or traditional methods to induce a termination seems to
be well known among Cambodian women,6–9 perhaps causing
women to delay seeking timely PAC. However, we know little
about the safety and efficacy of what women were using. The
resultant morbidity in Cambodia produced a distinctly differ-
ent severity distribution among the cases; more Cambodian
cases were serious, 42% versus 28% in Kenya and 10% in
South Africa.
An important difference in the study designs among these
three countries was the decision to collect data from health
centres in Cambodia. Regardless of a facility’s or provider’s
capacity to provide PAC, it is clear that women will seek care
at every level of the health system. Although women were less
likely to present at the lowest level health centres for abortion
complications, 86% of the facilities in the study encountered
at least one case during the study period. Many large Cam-
bodian health centres in the study have benefited from a long-
standing initiative of the government and non-governmental
organisations to improve PAC. It seems likely that women are
seeking care in these facilities because of increased confidence
in the performance and quality of the PAC services offered
there. The low-level rural facilities are often excluded from
these programmes and have been asked only to stabilise PAC
patients and refer them to another facility. An uncomplicated
‘incomplete abortion’, whether from attempted termination
or miscarriage, may be easily managed in a health centre; left
untreated, this simple case can rapidly become an emergency.
While there has been no formal documentation of seasonal
variation in pregnancy or PAC, seasonality of these events
would affect national estimates. Although every effort was
made to capture every case of complication from termination
and miscarriage, healthcare providers may have missed cases
and some women may have been reluctant to disclose a ter-
mination attempt, resulting in some underestimation.
On a national level, we did not capture cases treated in
private sector facilities or did we attempt to determine the
percentage of women who did not present at a health facility
for PAC. Previous studies conducted elsewhere have used
interviews with healthcare experts to estimate these propor-
tions and propose national data.11–14,27 These results are gen-
eralisable only to public sector health facilities. However, this
study design has distinct advantages over population-based
survey methods, requiring women to recall and disclose the
details and timing of past terminations to interviewers.33 This
study indicates that women’s disclosure may improve when
these data are collected by a healthcare provider, in a health
facility and in an environment where termination is legal,
during the course of their care. They may also have been more
likely to reveal this information to their medical provider, as
opposed to an interviewer, because it was directly related to
their medical history and subsequent treatment. In all cir-
cumstances, it seems unlikely that the methods used in this
study could overestimate the number of termination and mis-
carriage complications in the country.
In accordance with the study protocol, data capture forms
with missing gestational ages (34 cases) and cases of pregnan-
cies older than 21 weeks (12 cases) were excluded, although it
seems likely that some of these pregnancies were less than 22
weeks of gestation. Inclusion of these cases would have
resulted in higher national case estimates.
Finally, although referral to another facility was an out-
come, we did not attempt to follow women through the
course of their care. It is possible that a woman seeking care
for the treatment of complications may have been referred to
Abortion complications in Cambodia
ª2008 Ipas Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 965
another facility to complete her treatment. We chose to treat
each entrance into a health facility as a discrete case with its
own implications. Women referred to another facility may
have chosen not to go, gone to a facility not included in the
study, gone to a private or traditional practitioner or pre-
sented for care at another public study facility. As such, it is
possible the caseload estimates of complications from attemp-
ted terminations and miscarriages are a slight overestimation;
future studies using this methodology should attempt to
obtain valid information on progression of referral cases.
Conclusions
Eight of ten Cambodian women seeking services after an
attempted termination or miscarriage in the government sector
seek care in health centres rather than in hospitals; yet, almost
half of smaller health centres and many large health centres still
refer women to other facilities for routine PAC. Large health
centres appear to be the first choice for women seeking any
termination or PAC services. Improving health centre capacity
to provide this essential care must be a national priority.
It is clear that safe termination services should be more
widely available, as women seek such care wherever they
can. This study shows that abortion law reform is not enough;
it must be followed with concerted efforts to expand safe ter-
mination services. More than one-third (40%) of PAC clients
either reported or showed strong clinical evidence of att-
empted termination that was probably unsafe or at least unin-
formed. Further investigation is needed to better understand
the kinds of advice and interventions for termination sug-
gested by both medical and nonbiomedical practitioners.
The Cambodian health sector is faced with an urgent need
to increase the availability of second-trimester termination
services. Very few facilities are capable of providing the rec-
ommended evacuation procedures for safe second-trimester
terminations.29 Yet, 17% of women face increased risks
because they did not resolve their unintended pregnancy until
the second trimester. Training in second-trimester proce-
dures and wider use and availability of mifepristone and
misoprostol to facilitate this care could have a great impact
on access to appropriate care in the first and second trimester
of pregnancy. Seeking information and treatment from inef-
ficacious or unsafe providers has probably resulted in needless
delays in care and morbidity among these women.
More than one-third of women reported using contracep-
tion at the time of conception. Failure to ensure that they can
prevent a future unwanted pregnancy puts their lives and
health at continued risk. Better availability and accessibility
of the full range of contraceptive methods may improve con-
traceptive acceptance in PAC wards. Emphasis should be
given to expansion of more effective methods, including
long-term methods, and on ensuring provision of postabor-
tion contraceptive services at the location of care.
To reduce morbidity after termination or miscarriage in
Cambodia, it is imperative that measures are taken to encour-
age women to seek abortion-related care early and at appro-
priate healthcare facilities, while also raising the capability of
health centres to provide safe terminations and PAC. It is
necessary to educate and inform women of their safe, legal
and affordable reproductive choices should they face an unin-
tended pregnancy. Finally, ensuring that all women are coun-
selled and offered contraception so that they may effectively
control their own reproductive lives is both a health and
human rights imperative.
Acknowledgements
This study was made possible with financial contributions
from the UK’s Department for International Development. j
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Editor’s Commentary
The terminology of early pregnancy bleeding is in transition—away from abortion and towards termination, miscarriage
and loss. It used to be uncomplicated; abortions could be induced or spontaneous, missed, threatened, inevitable, incom-
plete or complete. Everyone in the medical profession knew what the terms meant and no one complained. The fact that the
term ‘abortion’ (from the Latin ‘ab’ away and ‘oriti’ to be born) encompasses a wide spectrum of tragedies—from recurrent
miscarriages in a 40-year old nulliparous woman to termination of an unwanted pregnancy in a 14-year old—mattered
little. Indeed, it was even convenient in situations where illegal induced abortions are common, as it allowed women to be
described according to their presenting symptoms rather than their unknown aetiology. And so the abortion terminology,
which dates back to 1540, remains the usual medical terminology for gynaecologists through much of the world. Both ICD-
10 and World Health Organisation (WHO) continue to use the terms.
And yet, the term abortion in popular culture has become synonymous with deliberate termination of pregnancy, and for
most of the 20th century, the term ‘miscarriage’ has been used instead to refer to a spontaneous abortion. It is only in
medical terminology that the use of the term abortion has persisted. And many young gynaecologists, myself included, will
have experienced this clash of cultures when a woman has reacted angrily to her early pregnancy bleeding being referred to
as ‘an abortion’. And so, in clinical practice, abortion is often used in medical circles, while the supposedly gentler term of
miscarriage is used when talking to women.
But changes are afoot. BJOG has had a policy of preferring the more patient-centred terminology (miscarriage, termi-
nation of pregnancy, retained products of conception) for several decades, and an expert group from the European Society
for Human Reproduction and Embryology have also called for change (R. Farquharson et al. Hum Reprod 2005;20:3008–
11). Indeed, documents coming out of the WHO also increasingly use the term miscarriage to refer to spontaneous
abortion, and there are suggestions that in time they may too change, together with the ICD classification.
Those in favour of change argue that it is inappropriate to have separate terminologies for medical and public use. It is seen
as elitist, a barrier to effective communication and prone to causing offence. Furthermore, the blurring of boundaries between
Abortion complications in Cambodia
ª2008 Ipas Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 967
induced and spontaneous abortions is often confusing as we found when editing this paper by Fetters et al. The general term
abortion in low-resource settings is often used to describe unsafe induced abortion when it really also covers spontaneous
abortions. And so it ends up being unclear whether the abortions referred to are induced, spontaneous or both.
The argument against change is both linguistic and political. Linguistic in the sense that the only single term that
encompasses both induced and spontaneous abortion is abortion. This is often needed in places where it is not possible
to differentiate the two clinically, as is so often the case in sites where induced abortion is illegal. Adapting it means having
to use the term ‘miscarriage and termination’, which often sounds clumsy and unnecessarily complicated. But there is
a political angle here as well. Some ‘prochoice’ activists are suspicious that the proposal to change the language is an attempt
to stigmatise the term abortion, and those undergoing and providing termination services together with it. Termination of
pregnancy, they argue, is best seen within the continuum of abortion and as an extension of normal biological process that
affects 15% of all pregnancies.
Readers will need to make up their own mind. BJOG made a policy decision to adopt the new terminology under the
editorship of David Paintin in the 1980s, and readers of this article will note how the authors have patiently adopted our
suggested changes (except for the title in which the term abortion was retained after much debate). For some, this may
appear odd, but we suspect that for most, it will make the article clearer, especially for those nonmedical readers who are
increasingly part of the readership. j
A Weeks
Fetters et al.
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