Background
Worldwide, the leading causes of maternal morbidity and mortality are direct obstetric complications and include hemorrhage, sepsis, hypertensive disorders, and abortion; the latter is responsible for 7.9% of maternal deaths globally and 9.6% in Sub-Saharan Africa (SSA) [1]. The World Health Organization defines unsafe abortion as a procedure for terminating a pregnancy performed by people lacking the necessary skills or in an environment, not in conformity with minimal medical standards, or both [2].
In Uganda, although the official data of the Ministry of Health indicate that abortion accounts for 5% of maternal deaths [3], the mortality due to abortion complications could be higher due to restrictive laws. It is estimated that 297,000 unsafe abortions are performed yearly, with an abortion rate of 54 per 1,000 women aged 15-49. Nearly 85,000 women have been treated annually for complications of unsafe that include incomplete abortion, sepsis, and uterine perforations [4] making it the main gynecologic cause of admission, leading to about 1,200 deaths annually [5].
The abortion rate is even higher in northern Uganda (70 per 1,000 women aged 15-49 years) [4], a predominantly rural region that is still recovering from a 20-year conflict that left many people displaced from their homes and economically disadvantaged. One of the factors contributing to the high number of abortion complications is the unmet need for contraception, which is still very high (28%). Contraceptive use in Uganda remains very low; only 17% of all women of reproductive age, and 18% of married women, utilize modern contraception [6]. This has resulted in a high total fertility rate (TFR) of 5.4 [7]. It is estimated that almost half of the pregnancies in Uganda are unintended, with 15% of the total pregnancies ending in unsafe abortion and constituting nearly one-third of the maternal deaths among the country’s young people [8]. The situation is even more dramatic among rural, poor, and less educated women, such as in the northern region.
Legal provisions for abortion in Uganda are very restrictive. Art. 22(2) of the Constitution of Uganda (1995) quotes: “No person has the right to terminate the life of an unborn child except as may be authorized by law ”. The Penal Code Act (Cap. 120), as amended through the Penal Code Amendment Act (No. 8 of 2007), Section 205, allows only abortion if “carried out in good faith to preserve the mother’s life” . Therefore, safe ‘legal’ abortion is not available and accessible, except for rare cases where it is the only way to save a woman’s life, and many healthcare providers prefer not to offer safe abortion to women who need it [9]. It is known that highly restrictive laws do not reduce abortion rates, but rather increase the likelihood of unsafe abortion [10]. Consequently, in a country like Uganda where abortion is highly stigmatized [11, 12], many women seek illegal abortion with unsafe traditional methods, offered by non-medical providers under unsafe conditions. While in urban areas the use of prostaglandin analogs is the most common method of unsafe abortion, in rural areas women resort to the intra-vaginal use of sharp objects (safety pins, nails, knives or sticks), to the ingestion of caustic substances (detergents or bleach) and more often to the use of local herbs, such as Commelina Africana and Vernonia amygdalina , which are readily available in the countryside [13].
In this small case series, we described two cases of unsafe abortions induced with very common herbs in northern Uganda, which ended up with severe complications and, in one case, led to the death of the woman.