There is a definite change in moral values worldwide. The former desire to preserve chastity before marriage has given way to the convenience of preventing or terminating pregnancy rather than avoiding pregnancy. The degree to which these attitudinal changes exist varies from country to country being most profound in industrially developed countries of Western Europe and North America. However the change is taking place rapidly and in a more confused fashion in some developing countries like Nigeria. This trend leads to an explosion in the incidence of unwanted pregnancies, a consequent increase in abortions which leaves a trail of immediate and remote dire consequences.
What is Abortion?
Abortion is defined as termination of pregnancy before 28 weeks gestation (that is 28 weeks from the date of last period). This is the definition in Nigerian Law. This of course is a direct offshoot of British Law. This definition is obviously deficient. The gestational age of 28 weeks was arbitrarily chosen in days gone-by as the mean gestational age for viability. However, with advancement in medical technology, babies born with birthweights of 500mg and above have fair chances of survival (This birthweight is consistent within 20 weeks gestation. Hence in some countries, abortion is defined as termination of pregnancy before 20 weeks while others use 22 weeks. What would you call a pregnancy that ends in live birth at say 26 weeks- an abortion? Most gynaecologists will regard it as an abortion if death occurs soon after and as a premature delivery if life is sustained.
Abortions are classified in a number of ways. Most cases of bleeding in “early “pregnancy are due to abortion, thus the major classification is progressive according to the stage of the clinical events.
Thus you have:
(a) Threatened Abortion:
When there is only bleeding. Some of these will resolve and pregnancy will continue to maturity. Others will progress to
(b) Inevitable Abortion:
When in addition to bleeding, there is abdominal pain and opening of the entrance (or outlet of) the womb-the cervix.
In addition to (b) above, some of the products of conception have been passed while some is retained in the womb.
(d) Complete Abortion:
When all the products of conception have been passed out.
(e) Missed Abortion:
In this category, the foetus dies in the womb, but is not expelled. There may have been slight bleeding in the past which stopped and may have been forgotten by the patient. The patient may think she is still pregnant especially if there has been a history of infertility –in which case time and care should be taken by the doctor to adequately explain to the patient that the pregnancy “has died”, otherwise the patient will reject appropriate treatment.
Abortion may also be classed as septic or non-septic depending on whether there is evidence of infection. Some abortions are spontaneous, others are induced depending on whether there has been intervention which may be by physical or chemical means or use by drugs. In our society, the term abortion refers to the induced variety, while spontaneous abortion is acknowledged ONLY as MISCARRIAGE. It is therefore common to find patients (even those with Ph. D) denying having had abortions, while volunteering that they had suffered a number of miscarriages. This is no doubt because induced abortion is further classified as Legal or Criminal, the overwhelming majority being of the criminal variety. Abortions are also classed as Early or Late depending on whether they occur in the first three months of pregnancy or after.
Finally, abortions are classified as Isolated or habitual (Recurrent). Habitual (Recurrent) abortion is defined usually as a sequence of three or more consecutive abortions. However, some gynaecologists take two or more as a standard.
Fifteen to twenty per cent of all pregnancies end in spontaneous abortions. No one knows the precise figure even in advanced countries where there is an established culture of record keeping and accurate documentation. The problem of the exact incidence of wasted pregnancies is compounded because some pregnancies are lost before they are clinically identifiable, that is abortions occur without the patients knowing they were pregnant.
On the other hand, some patients have prolonged menstrual cycles which may be sporadic (i.e. persistently irregular cycles) and some of these patients count these long cycles as miscarriages.
This is so very common among patients presenting for infertility treatment in our society. It provided dome measure of succour Albert psychologically that they had been pregnant and gives hope to their husbands.
On the balance, it would appear that the incidence of spontaneous abortions is grossly understated at 15 to 20%. Using very sensitive techniques, pregnancies can be diagnosed even before a menstrual period is missed. A recent study with this techniques showed that out of 152 conceptions diagnosed, 65 ended in abortions, giving an abortion rate of 43%. Of these abortions, only 15 were recognised as clinical abortions while 50 were unsuspected clinically.
Spontaneous Abortions (Miscarriage)
There are many possible causes for abortion and more than one may operate at a time. In practice and without special investigations, it is not possible to tell the exact cause of abortion in a patient.
In the early weeks of pregnancy, death or disease of the foetus often precedes the expulsion from the womb and appears to be the precipitating factor for abortion.
Later in pregnancy, sometimes the foetus is born alive and it would appear that the failure of the womb to accommodate the pregnancy is the main cause of the abortion. It is therefore helpful to examine the causes of abortions from these two viewpoints.
A.Foetal death or Disease
This may be caused by any or a combination of the following:
(i) Abnormal Conceptuses:
This is the commonest single factor associated with abortions and is said to account for 50 to 80% of spontaneous abortions. Malformation of the foetus or its membranes may be caused by:
(a) Defective Implantation of a normal embryo.
(b) Maternal Virus infection (especially rubella)
(d) Genetic (hereditary) factors.
(ii) Foetal Anoxia:
When the supply of oxygen from the maternal to the foetal circulation is in adequate. This may exist for different reasons like:
– Maternal hypertension
– Placental Separation
– Abnormal placenta
– Cord accidents like knots
– Maternal “suffocation” due to diseases like heart failure or severe acute respiratory disease.
(iii) Incompatibility between the blood groups of foetus and mother. (Especially rhesus incompatibility with iso-immunisation).
(iv) Poisons and Drugs.
Chemical poisons are rare causes of abortions and that is why even large doses of some agents wrongly believed to be abortifacient (abortion inducing) usually have no effect. However, anti- cancer drugs readily cause abortion by killing the foetus.
Syphilis is the classic example of maternal infection that spread across the placenta to the foetus and cause foetal death.
Very high fever in the mother from any cause may lead to abortion.
B. Failure of the uterus to accommodate the pregnancy
(i) Development errors: When the womb of the pregnant women is structurally abnormal. This is not very common.
(ii) Displacement of the Womb
There is a common belief that backward displacement of the womb (….retroversion) frequently causes abortions. (Some women will tell you that the doctor said that my womb has fallen back). This is an outdated concept and it is now well established that only very very rarely may be retroverted uterus be a causative factor in the genesis of an abortion. This displacement of the womb is consistent with normal fertility and delivery. It is therefore, nowadays very rarely necessary to perform the operation “to turn the womb forward.” WE ADVISE THAT ANY PATIENT OFFERED THIS OPERATION BY ANYBODY ESPECIALLY AS A FIRST MEASURE IN SOLVING ANY CHILD-BEARING PROBLEM SHOULD AT LEAST SEEK A SECOND OPINION.
(iii) Stimulation of Expulsive Uterine Action.
Nervous shocks: – This may precipitate abortion in the susceptible woman, but this is unusual. This is more a fiction story variety than real life factor. Usually, women go through tremendous emotional turbulence (accidents, operations, frights, etc.) with their pregnancies intact.
(iv) Overdistension of the Uterus
This partly accounts for the high abortion rate in multiple pregnancy.
(v) Cervical Incompetence
This is the most prominent accommodation factor in the cause of abortions. The weakness of the neck of the womb (cervix) leads to the opening of the womb as pregnancy grows and then the bag of waters breaks and the baby “drops down” with little or no pain.
Recurrent Habitual abortion
One of the previously stated recurrent or habitual abortions is defined as the occurrence of three or more consecutive abortions. Many gynaecologists however, accept two or more consecutive miscarriage as habitual abortion especially in women greatly desiring children.
One of the most pathetic circumstances in gynaecological practice is managing a patient who though desirous of children has just had 5th or more consecutive abortion.
Late Habitual Abortion (Miscarriage).
Habitual abortion may be early or late. Late habitual abortion which occurs from the 14th week to the 27th week (midtrimester) is usually due to structural defect of the womb. This most common defect is a weakness of the neck of the womb (cervical incompetence) which leads to opening of the outlet of the woman as the pregnancy grows after the first 3 months.
The structural defect may be due to inborn abnormalities in the womb which make it difficult for the womb to “expand” with the advancement of the pregnancy thus leading to contractions and eventual abortion.
Structural womb defects are amenable to surgery, and proper diagnosis and treatment may lead to the achievement of normal pregnancy and live birth.
Early Habitual Abortions
It is well established that the hormones (“chemicals) produced by the ovary and later by the placenta are important in sustaining pregnancy.
It was therefore, assumed that the hormone deficiency is the main cause of recurrent early trimester abortion. Hormone treatment was therefore very fashionable in days-gone-by in cases of early trimester threatened abortion. (All sorts of hormones were used –thyroid extract, oestrogens, progestogens, and oestrogen – progesterone mixtures). Many of these have gone out of fashion especially when it was found that female babies born to mothers who were given oestrogens in early pregnancy, tended to develop some type of vaginal cancer more than the general public.
Present scientific conclusion is that there is NO MATERIAL BENEFITS from the use of these drugs. They are as effective as PLACEBO (Preparations with no drug in them).
Doubtless some sort of treatment will continue to be given. These patients are in desperate need to help from doctors.
The arguments marshalled to answer the above question go beyond the level of the discussion in this article. Present scientific conclusion is that there is NO MATERIAL BENEFITS from the use of these drugs. They are as effective as PLACEBO (preparations with no drug in them).
Doubtless some sort of treatment will continue to be given. These patients are in desperate need to help from doctors. Results indicate that the psychological support of being on treatment does improve the chances of achieving a live birth. Psychological support is a very beneficial factor in medical practice and the benefit may not only be anxiolytic (anxiety relieving) but there may be material benefit via some nervous pathways. However, since equivalent result is achieved via this psychological support whether hormones or placebo is given, intellectual honesty demands that a real placebo should be given. It is also much cheaper and the risks of injections are avoided. This is the tendency in practice among gynaecologists in most advanced countries
In Nigeria, active hormonal products remain fashionable. Why? It is my personal view effecting changes as this in treatment habit in a country like ours is near impossible. There are untutored and untrained people issuing prescriptions and counseling to patients who are mostly ignorant. The leveling-down mentality of the Nigerian society also forces trained practitioners to persist in this largely harmless but expensive habit – most patients will desert a practitioner in Nigeria who rightly counsels them to accept a scientifically superior alternative rather than a popular, unnecessary and expensive one.
Things will change when our illiteracy level reduces (dear reader, have you noticed how much juju films our children are forced to watch on television while their counterparts in the developed countries soak in the technological wonders of the computer age? It’s all part of the leveling-down mentality that pervades the society which thus operates at the market woman’s and motor-park tout’s values system.
Induced abortion is abortion that is precipitated by intervention which may be by physical or chemical means. Most times when people talk about abortion in general discussion, it is induced abortion they are discussing. Induced abortion has legal, medical and social implications.
Induced abortion may be legal or criminal. The laws guiding induced abortions vary from country to country and has undergone significant changes from time to time in some countries, while it has remained unreviewed in some other countries despite a steady flux in moral and cultural values.
A global look at abortion laws show 3 distinct varieties.
(i) Those that FOCUS ON THE INTENT TO INTERRUPT PREGNANCY.
(ii) Those that require proof of pregnancy
(iii) Those that make Abortion readily accessible for a wide variety of indications.
The laws thus range from the extremely restrictive that categorises abortion as a criminal offence in all circumstances through those that allow abortion to preserve the life or health of the pregnant woman or in cases of rape or incest for defective foetuses, to more liberal laws that allow abortions even for socio-economic reasons and therefore on request. Table below shows the percentage of the world population living under the difficult categories of abortion laws (as of 1978) 9tietze 1979).
Abortion laws are obviously very liberal in most parts of the world.
Section 228 of the Nigerian Criminal code states thus:-
“Any person who with intent to procure the miscarriage of a woman whether she is or is not with the child, unlawfully administers to her or causes her to take any poison or other noxious thing or uses any force of any kind or uses any means whatsoever is guilty of a felony” ………….This is a direct inheritance from the laws of the United Kingdom with the passage of the Abortion Act of 1967, we here have remained stuck to the law.
Two court cases are instructive to the position of our present abortion laws. In R V Spicer, Spicer had “helped” a woman 2 or 3 months pregnant by inserting 2 fingers in the vagina and “turning” the uterus. Some days later, the woman suffered a miscarriage and sued the doctor.