Ensuring that women have access to safe abortion is “pro-life”

I first met Nesta at about 2 am. She had been brought to the hospital late evening, confused, febrile, and hypotensive. I diagnosed septic shock, and we treated her with intravenous fluids and antibiotics. Initially, I was not too alarmed by the lack of urine in her bladder. This, I thought should remedy itself with our treatment. I was, however, uncertain about the history she insisted was hers. It is after all unusual practice to perform a dilatation and curettage for chronic pelvic pain. Still this was Liberia, and I’d seen far stranger.

By morning, and several litres of intravenous fluid and high doses of diuretic later, I was becoming more concerned about our failure to extract any of Nesta’s urine. She was increasingly confused, but still able to adamantly deny that she had had an abortion.

Being a pragmatist I washed out her bladder and thereby confirmed her pregnancy. Dilatation and curettage showed offensive products of conception, but her abdomen was soft with no evidence of a perforation. Fabulous.

It doesn’t matter how often you check, flush the catheter, or press on a patient’s bladder. If they’re in renal failure it doesn’t seem to make a great deal of difference. Intravenous fluid and furosemide can of course help at times, but as the day and night passed and as her temperature settled and blood pressure normalised, it was, I realised, dialysis that Nesta needed.

I discovered the next morning that Liberia has no dialysis facilities. One clinician helpfully advised that I could take her to Ghana. By now Nesta was bloated and semiconscious. I was worried that she might be better off with a general physician, in another hospital perhaps, in the care of someone with a better understanding of the pharmacokinetics of furosemide; someone who understood the inner magic of the loop of Henle; someone with access to biochemical tests; someone, maybe, who was used to watching a patient die from renal failure; someone who wasn’t me.

I spoke to my more learned colleagues by satellite phone. I put in abdominal drains. My nurses and I followed and concocted the peritoneal dialysis ingredients like we were reading a prayer. It worked for one of our patients before, they told me. One of the clever German doctors did it, they said. Maybe she’ll be OK.

She wasn’t, of course. It was too late. We transformed her slim body into a bloated version of itself, and then she died. She had been killed by an unsafe abortion, leaving her children vulnerable in a country where even with a mother they have a one in 10 chance of dying before their fifth birthday.

A few days later we admitted Grace to our hospital. She did not deny having had an unsafe abortion, however. Grace was already beyond commenting on the subject. I evacuated the infected pregnancy from her womb, and then watched her die from sepsis. It took less than 24 hours, prolonged slightly, perhaps, by the antibiotics and adrenaline I hopefully and helplessly administered to her. I remembered the first patient I had watched die in the same hospital and how upset and inadequate I had felt. Ten months later while I watched Grace die I wasn’t upset: I was angry.

This was not one of my better weeks in Liberia. Nor, though, was it an exceptional week. In the 10 months I worked in Liberia, unsafe abortion was the leading cause of maternal death. Eight of our patients died from the complications of an unsafe abortion in this period, outranking more recognised causes of maternal mortality such as haemorrhage, eclampsia, and sepsis.

Shocked by what we saw, my colleague and I started a record of our medical activity related to abortion. In just over two months, we treated 110 women with complications of miscarriage and abortion. Of these, 52 admitted that they had self induced their abortions, 25 by undergoing an unsafe dilatation and curettage, 17 by drug overdoses, seven by consuming toxic herbs, and six by introducing sticks into their own uteruses.

Commonly, the dilatation and curettage described involved only the introduction of an instrument through the women’s cervix, and no evacuation of any products. Our patients reported that this procedure could be bought for $10 for each completed month of pregnancy and was performed without analgesia or regard for sterility. Two women had paracervical perforations and a closed cervical os, their abortionist having clearly missed the cervix entirely. Both had denied undergoing an abortion until we discussed these findings with them.

The most common complication we saw was that of an incomplete septic abortion (31 women). Other complications included pelvic and abdominal abscesses (6), haemorrhage requiring a blood transfusion (7), and herbal intoxication (4). Five patients underwent a laparotomy, 51 required dilatation and curettage for retained products, and two patients died from herbal intoxication.

Unsafe abortion is a little discussed yet major cause of morbidity and mortality in countries like Liberia, which are unable or unwilling to provide safe abortion services. In the United Kingdom it has become easy to disregard the harm that our reproductive health services prevent. We must protect and promote access to safe abortion services. Safe abortion is pro-life. Safe abortion saves lives. Just ask your grandmother.