Dorothy Kweyu
15 April 2008
Nairobi — Could the clamour for freer access to abortion be hindering doctors from tackling an even greater killer of women - bleeding after birth?
That appears to be the case in the latest Nation inquiry into women's health, which, in recent years, had tended to zero in on greater access to abortion as the best safeguard against maternal mortality.
Of even greater concern to some doctors is that figures touted as representing deaths from abortion have been twisted to push the case for liberalised abortion.
A consultant obstetrician and gynaecologist, Dr Jean Kagia, told Nation that contrary to widely held views that abortion death rates in Kenya were spiralling, hospital deaths have remained constant at 800 over a long period.
Quoting a 1982 study by Aggarwal V.P. and Mati J.K.G. titled: "Epidemiology of induced abortion in Nairobi, Kenya, appearing in the Journal of Obstetrics and Gynaecology for East and Central Africa", Dr Kagia poked holes into the latest Ipas study, which typically heightened calls for unhampered access to abortion services.
Break down
According to the Ipas study, which was published in the June 9 issue of Saturday Nation, about 316,560 abortions occur in the country annually. Out of these, an estimated 20,893 women are hospitalised with abortion-related complications.
Without disputing the Ipas figures, Dr Kagia took issue with the pro-abortion slant of the study that failed to credit Kenya for keeping abortion deaths at an average of 800 per day over the past 25 years since the groundbreaking Aggarwal/Mati study.
The greatest problem with the Ipas study, Dr Kagia pointed out, was that it did not break down the figures to distinguish which of the 800 or so abortions were induced, and which ones were spontaneous - the so-called miscarriages.
"If you look at their statistics, you will find that maybe about 28 per cent of them were what you would say, obviously this looks like it was actually an induced abortion," the doctor said, and cited fever, a foul smell or discharge, as some of the signs of interference with pregnancy.
"Something like 44 per cent of the abortions would be spontaneous," she said, while the remaining causes would be unclear.
The dean of the School of Medicine at the University of Nairobi, Prof Zipporah Ngumi concurs with Dr Kagia on the questionable conclusions of the Ipas study.
"There are many pregnancies that don't go to term," she said, and gave an example of two young women whose integrity she vouched for, and who recently had spontaneous abortions.
"I mean, the baby just comes out. You are not in control of that, and the babies that come out are babies that might not go on to term or they have congenital deformities that will not allow them to survive," the don said.
Induced abortion
In fact, an earlier study (1996) titled "Complications of unsafe abortion in sub-Saharan Africa: a review", acknowledges problem with assigning specific causes to induced abortion on the continent.
Written by Janie Benson and Lori Ann Nicholson of Ipas, Lynne Gaffucin of the Johns Hopkins Programme for International Education in Reproductive Health, and Mr Stephen Kinoti of the Commonwealth Regional Health Community Secretariat for East, Central and Southern Africa, Arusha, Tanzania, the article says in its literature review:
"The criteria and methods used for differentiating between categories, however, were often unclear in these articles. In other studies, incomplete abortion cases or deaths resulting from complications were investigated, without distinguishing between induced or spontaneous abortions."
Dr Kagia is now calling for a proper knowledge, attitudes and practices (Kap) study to determine the state of abortion in Kenya, based on interviews with the general population, since most studies being cited to liberalise abortion in the country are hospital-based.
Her call, she said, is based on the fact that a Steadman opinion poll showed that some 80 to 85 per cent of Kenyans opposed abortion.
And she wants attention deviated from the quest for unrestricted abortion to what she considers to be the real killer of Kenyan women - bleeding after birth.
She listed other causes of maternal death as obstructed labour, caused by difficulty in expelling the baby's head from the birth canal, high blood pressure and infections.
Mortality
"By the time you bring abortions, abortion will be a very small thing. And even internationally, abortion is not a major cause of maternal mortality," she said.
In most cases, abortion accounts for 13 per cent of women's deaths after other factors, Dr Kagia said.Medically known as post-partum haemorrhage (PHH), bleeding after birth claims far more women than abortion worldwide, the Nation established.
Quoting Malcolm Potts, an international population personality, Janet Wells says in a June 2006 article: "Without intervention, a woman with severe post-partum haemorrhage can bleed to death in three to four hours. The blood gushes out, "like cutting an artery" - a terrifying situation for the woman, and for any health practitioner."
An Internet article of the National Health Service of Scotland shows that a woman is at risk of PPH if she has suffered previous bleeding in pregnancy, and if the placenta presents before the baby.
A woman who has had multiple pregnancies is at five times greater risk of bleeding after birth.
High blood pressure in pregnancy also exposes a woman to a four times higher risk of post-partum haemorrhage, which also affects females of Asian origin two times more than others.
Retained placenta is another cause of PHH, while labour that lasts for more than 12 hours exposes a woman to the danger of over-bleeding.
During a 2006 technical consultation of the World Health Organisation (WHO) PPH was described as the world's leading cause of maternal mortality, responsible for some 60 per cent of mothers' deaths.
Because of the grave danger of death posed to women by post-partum haemorrhage, the doctor, who has recently testified before the US Congress foreign affairs committee, where she was described as a "Warrior on human rights", now wants greater attention paid to post-partum haemorrhage, and less to abortion.
Private sector
As the national co-ordinator of an emergency programme for treating women in labour, Dr Kagia is involved in conducting two-day refresher courses for doctors and nurses, where they apply humanistic approaches to improve the care of women during delivery. The programme involves medics from both the public and private sector.
The doctor is also a founder-member of another programme, known as the Institute of Family Medicine, which is supporting a Masters of Medicine in Family Medicine programme at Moi University, and has outreach in Rwanda.
Prof Ngumi is the vice-chair of the programme. Kijabe, Tenwek and Chogoria hospitals are involved in the project.
"We have tried to do a lot to improve maternal mortality of the women, by getting better health care of the general doctors, who are going to get postgraduate care so that when a woman comes, they can do a Caesarean section safely, they can remove an appendix safely, they know about the community (they are working in), the have knowledge of the women or diseases of the community we are acting in," Dr Kagia says.
And what is her last word? "We should be putting more energy into stopping maternal deaths than in calling for freer access to abortion. Mothers are dying, and we have tools which we can use."
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