Profile of Women receiving Second-trimester Safe Abortion Service at Paropakar Maternity and Women’s Hospital

Background Second trimester abortions account for a small percentage of abortions globally. Abortion is one of the safest medical procedures. Accessibility of safe and high quality second-trimester abortion care can decrease severe complications associated with it. Objective The profile of women undergoing second-trimester abortion was assessed during the study. The profile includes demographic and clinical aspects. The study also aims to find out the rate of surgical and medical methods of abortion and to understand its indications.


INTRODUCTION
In Nepal, there are an estimated 539,000 unintended pregnancies each year which contribute to 45% of all pregnancies, the majority of which result from an unmet need for modern contraception and access to the full spectrum of sexual and reproductive health services. 1,2 Access to safe abortion, family planning services and postabortion care are critical for maintaining women's ability to control their fertility, protect their health, and ensure the wellbeing of their families. 3 Abortion services in Nepal are legal in second trimester only when the pregnancy was a result of incest or rape upto 18 weeks or at any stage of pregnancy if it poses danger to the physical or mental health of the pregnant women or when it is associated with fetal death or fetal anomaly after approval from a medical practitioner. 4 Though second trimester abortions are performed at fewer rates than at first trimester, it accounts for complication at a higher proportion. The rates of second trimester abortion have been increasing because of the prenatal screening programs during antenatal visits, detecting women whose pregnancies are complicated by serious fetal abnormalities.
There are variations in the profile of women receiving safe abortion services. Demographic factors such as age, education status, and employment and clinical factors such as past pregnancy history, indications of abortion, and method used are determinants showing variations. This study was done to determine the demographic and clinical profile of women receiving the second-trimester safe abortion services in one of the major abortion care provider centers.

METHODS
This was an observational study where we collected retrospective data from charts of the clients who received second trimester safe abortion service. The study was conducted at the Paropakar Maternity and Women's Hospital, a leading tertiary care center. The duration of the study was in between the period of Shrawan to Magh of 2077 B.S. A total of 100 women who visited for secondtrimester abortion were selected.
Women seeking second trimester abortion must undergo a detailed demographic and clinical profiling. Age, address, educational status, employment, marital status, past pregnancy history, family planning practice and indication of abortion are amongst the most important components. After abortion was performed further details like method used for abortion and complications associated with it were also collected. This information was then enlisted over the Health Management Information System (HMIS) chart by a medical service provider. Our study included women of age group 15-49 years seeking second trimester abortion (12-24 weeks) and excluded those with incomplete information, and pregnant clients < 12 weeks of gestation.
The indications of the medical termination of pregnancy were provided under the legal framework of the Nation which are grouped under maternal and fetal causes.

Physical health
The health of the patient is at risk if the pregnancy is continued due to medical conditions and has been referred by the physician for the termination of pregnancy.

Mental health
Either a psychiatrist has referred the case for termination or at least three out of 11 positive responses in Nepali language were qualified to a mental health checklist in "the Client Personal Profile"(yellow form) prepared by the Department of Health Services, Ministry of Health.

Rape/Incest
Termination of pregnancy was carried out if the patient requests for this on the ground of rape or incest without asking further detail questions about rape.
The data for our study was retrieved from the record section after Institutional Review Committee (IRC) approval. Information collected was calculated on MS Excel and presented in the tables.

RESULTS
A total of hundred women had visited the comprehensive abortion care center of Paropakar Maternity and Women's Hospital during the period of seven months from Shrawan to Magh 2077 B.S. None of the participants were excluded as the information and inclusion criteria was satisfactorily maintained. Table 1 shows that majority 31 (31%) women visiting the comprehensive abortion care center for secondtrimester abortion were of age group 15-20 years. The minimum and maximum age of women receiving care were 13 years and 46 years respectively. Many women were literate (able to read and write) (69%), 38 (38%) women among the total of 100 were nulliparous and 55 (55%) women were residents outside of the Kathmandu valley. Table 1 also shows that most of the women have had at least one live birth (62%) with one participant having highest parity of 7. A post abortion counselling regarding contraceptive use after abortion service, yielded 56 (56%) of women who opted for using a contraceptive method after the abortion procedure. Among the users, oral contraceptive users were 18 (18%) followed by condoms by 17 (17%) of the client's partner. Table 2 shows that most women who visited were of earlier gestational age (47%) of 12-14 week of gestation. Table 3 shows the major indications of abortion. The most common indication was maternal mental issues (32%) followed by maternal medical illness (20%). Intrauterine fetal death and fetal malformation were other important indications. There were 7 (7%) cases where pregnancy was due to rape 2 (2%) cases were due to failed medical abortion.
Medical method of abortion was preferred in most of the cases (Table 4).

DISCUSSION
In our study it was seen that the number of the women undergoing second trimester abortion was maximum in    the age group of 21-25 years. Most of the women were literate (79%) and the majority had given birth to a child before (62%). This is in contrast to the study performed by Karki et al. where the majority fell on the age group of 26-30 years (33.33%). Mental cause appeared to be the major reason for abortion constituting 82.04%, the rate of which is higher compared to the rate from our study (32%). 5 The demographic pattern obtained from our study is similar to another study performed in Ethiopia which showed that amongst the women undergoing second trimester abortion (total: 201) the average age of participants was 21.26 year. More than three-fourth i.e., 170 (84.6%) were single in marital status and 168 (83.6%) were literate. Almost twothirds 131 (65.2%) had no history of using contraceptives. 6 Our study however showed that 79% were literate and had received some form of education above the primary level. Agrawal and Salhan also observed that the majority of women (70.7%) were educated and 34.8% were uneducated. This highlights the importance of education of any kind and its impact on the overall women's health especially regarding abortion. 7 The rate of medical induction in our study was 71 (71%) and surgical evacuation was 29 (29%). In Sharma et al. hospital based descriptive study, among 40 women, who had termination of pregnancy at second trimester, 37 (92.5%) had successful medical termination whereas 3 (7.5%) needed dilatation and evacuation. 8 Most of the surgical abortions performed in our study was done only after the failure of medical method or following complications of medical abortion such as bleeding or retained product of conception.
The most common reason for late abortion in our study was maternal cause such as maternal mental illnesses (32%) followed by medical problems (20%). Criteria must be fulfilled to give the designation of mental illness. It is done by the service provider's subjective perception. In a study by Pattainaik et al. it was found out that among the various reasons given by patients for undergoing an abortion, the most common reason was found to be poverty accounting about 39.4% and 17.2% of cases were due to gender based preferences. 9 Another study by Shivakumar and Vishvanath, an unplanned pregnancy (30.7%) followed by contraceptive failure (29.3%) were amongst the commonest reasons. 10 One study by Bahadur et al. cited termination of unplanned pregnancy (32.8%) as the most common reason, poverty in 24.6%, contraceptive failure in 22.3% and completed family in 20.3% of women. 11 Our study has highlighted the maternal and fetal causes of abortion. Maternal causes accounted for maternal medical and mental illnesses. This is followed by fetal causes such as intrauterine fetal deaths and fetal abnormalities that mostly resulted in either spontaneous or induced abortion. Rape (7%) also accounts among the major reasons of legal abortion. There is a need to make women aware of the legal causes of abortions and the need to have continued prenatal care to diagnose and intervene in cases of need such as intrauterine fetal death and fetal abnormalities. The role of post-abortion counselling holds equal importance to avoid repeated abortions and improve contraceptive compliance.
Acceptance of family planning service following abortion is also now a very important concern. Though major part of it is dependent on its accessibility and ease of use, another important aspect of it which is equally important is to understand the effectiveness of post-abortion counselling. Our study showed that at least 44 (44%) women had some reluctance in using a contraceptive method following abortion, however 56 (56%) accepted it well among which oral contraceptive pills were the most preferred ones. The data is different from one study by Shrestha et al. where the contraceptive acceptance was only 350 (49.5%) with injectable depot medroxyprogesterone being the most accepted one. 12 The cause of reluctance in following family planning methods could be many as it is difficult to point out a single reason. It is important to mention that postabortion counselling should not be just restricted towards a female user or the patient but should diverge into a more couple based approach. This is important in a sense that whenever a counselling is couple based, the decision can be mutual and compliance is greater.
Medical and surgical methods of abortion for second trimester are one of the most common procedures performed in reproductive-aged women and when performed by a skilled provider in the appropriate setting, it is one of the safest procedures. 13 Accessibility to safe abortion service and effective post-abortion contraceptive counselling must be emphasized as there is an interconnectivity in sexual and reproductive health and rights, education; poverty; and women's personal, social and economic empowerment.
Abortion is one of the common medical procedures and an essential component of sexual and reproductive health care. Despite its usefulness many women still face barriers to safe abortion, and their pathway to care is influenced by a number of social, cultural and legal factors. In our study we evaluated data collected retrospectively because of which we were unable to explore much into the history regarding the indications of abortion. Also it is hard to point a single reason for abortion because though one tops another there are often multiple reasons indicating the need for abortion. The evaluation of mental illness is also subject dependent. It was also difficult to obtain information regarding the past and future family planning methods, its usage and effectiveness.

CONCLUSION
Second trimester abortions accounts for a smaller percentage of abortion. There are both maternal and fetal indication of abortion. Women's medical and mental condition, having little knowledge regarding the availability and accessibility of safe abortion services, victims of sexual assaults, intrauterine fetal death and fetal anomalies all account for the reasons of abortion. Post-abortion care is an opportunity for healthcare professionals to provide essential and efficient information for achieving positive health outcome for women. Efficient and equitable distribution of family planning services are the most essential component of safe abortion service.