Abortion is the termination of pregnancy before the age of viability of the fetus. Abortion can be classified as either spontaneous or induced, early or late and safe or unsafe  . World Health Organization (WHO) defines unsafe abortion as a procedure for termination of a pregnancy done either by an individual lacking the necessary training or in an environment not conforming to minimal medical standards or both .
Abortion is a major public health problem especially in developing countries, resulting in severe complications including maternal death . Globally, it is estimated that one in every five pregnancies ends up in an abortion . According to WHO, about 56 million abortions occur worldwide each year, with over 25 million (45%) of them being unsafe  . In a 2017 United Nations database report, countries with more restrictive abortion laws had about four times higher unsafe abortion rates and maternal mortality ratios (MMR) . Over 13% of maternal deaths in the world are attributed to unsafe abortions and its complications such as bleeding, pelvic infection or abscess, genital trauma, secondary infertility and death  . Worldwide, an estimated 7 million complications result from unsafe abortions . This alarming figure is maintained by the very high proportion of unintended pregnancies in these developing countries.
Sub-Saharan Africa (SSA) is the most hit region as far as unsafe abortion related maternal morbidity and mortality are concerned . While it is estimated that 30 women die for every 100,000 unsafe abortions in developed countries, over 520 women die for every 100,000 unsafe abortions carried out in SSA  . Likewise, while the African region sees 29% of all unsafe abortions, it contributes 62% of the total unsafe abortion-related maternal deaths  . WHO estimates that 30% - 40% of maternal deaths in SSA are due to induced unsafe abortion  . This is partly due to the restrictive abortion laws in most countries of SSA and equally the low modern contraceptive use . Of the 214 million women having unmet needs for family planning, 24.2% are from Africa 
The Sustainable Development Goals (SDG) 3.1 states that “the global maternal mortality ratio should be reduced to less than 70 per 100,000 live births”  . Post abortion care (PAC) through manual vacuum aspiration (MVA) of retained products of conception is one of the seven signal functions of basic emergency obstetric and newborn care (BEmONC) and this constitutes one of the global strategies for the fight against unsafe abortion-related maternal mortality .
Post abortion care (PAC) directed at women with incomplete abortion is a package of five activities as shown in Figure 1, which include: 1) the emergency management of complications related to abortions; 2) offer counselling on the patients’ needs and family planning; 3) the provision of modern contraception; 4) linkage to other reproductive health care services such as screening for sexually transmissible infections and gynecological cancers; and 5) to facilitate her social reinsertion and prevent future unsafe abortion cases via provider-community partnership .
The maternal mortality rates (MMR) of Cameroon, which stands at 782 maternal deaths per 100.000 live births is one of the highest in SSA and has been rising over the past two decades  . One of the main reasons is explained by the low modern contraceptive prevalence rate (CPR) of 19.3%, the high unintended pregnancy rate of 40%, high unsafe abortions and the insufficient care for these women  . Abortions account for about 30% of total maternal deaths in the country   . In a country like Cameroon, where all previous measures implemented over the decades have not succeeded in reversing the MMR, ignoring a determinant factor such as contraception, can only render the fight impossible to win.
Cameroon is a country where abortion laws are restrictive, allowed only in cases of rape and to save mothers life . This has led to an increase in unsafe abortions and thus maternal morbidity and mortality  . The main strategy to fight maternal deaths is to offer comprehensive abortion care where possible. It entails providing safe abortion, where country laws permit and quality post abortion care (PAC). The WHO recommends that quality PAC be offered in all the health facilities (HF) in the country and by all trained health cadres .
In order to understand how PAC is practiced in Cameroon, and how these services can be improved so as to help curb the rising abortion-related maternal deaths, we conducted this literature review of successful approaches of PAC in other sub-Saharan African countries with similar contexts. Our goal was to draw lessons from these countries and make evidence-informed recommendations in order to improve the uptake and quality of PAC services offered in Cameroon.
On the 24th May 2018, we searched for published articles on post abortion care
Figure 1. The five core components of the post abortion care (PAC) model.
services offered in SSA in the following databases; Cochrane (CENTRAL), POPLINE, African Index Medicus (AIM), GOOGLE SCHOLAR and MEDLINE using diverse and relevant Medical sub headings (MeSH) and search terms concerning our topic of interest, such as; “Post abortion care” AND “Sub Saharan Africa”, “Abortion care” AND “Africa”.
All articles which met with the following criteria: 1) Published in English language only, 2) Published between the years 2000 and 2018, 3) Both experimental and non-experimental studies, 4) All articles addressing at least a component of post abortion care either in a specific country, or in a sub-region or in the entire SSA region; were included in the study.
Data collection and analysis
For each selected article, we screened the abstracts for eligibility, noted the study design and extracted the results and lessons learned from the study.
Ethical clearance was obtained from the Institutional Review Board (IRB) of the Institute of Tropical Medicine (ITM), Antwerp in Belgium.
Information from each selected article was entered into a summary table of four sections: study selected, study design, country and outcomes. After excluding irrelevant articles and duplicates, we found a total of 30 articles which met with the inclusion criteria, as shown in Figure 2. The number of articles retrieved from each of the databases was as follows: MEDLINE (11), POPLINE (09), GOOGLE SCHOLAR (06), COCHRANE CENTRAL (02) and African Index Medicus (02). These studies were conducted in a total of 16 SSA countries representing all the four sub-regions as follows: 3 from Cameroon (Central Africa), 4 from Southern Africa, 10 from East Africa and 13 from West Africa as shown in Table 1.
According to their strengths of evidences, we retrieved a systematic review with meta-analysis on septic abortion. There were three systematic reviews, on the timing of PAC-IUD insertion, the safety and effectiveness of abortion care by midlevel cadres and doctors, and PAC in 14 countries in east and southern Africa. We equally found one literature review on the role of midlevel staff in PAC. There were two randomized controlled trials (RCTs); one in Burkina Faso on the safety and effectiveness of misoprostol versus MVA in PAC, while the other verified differences between PAC misoprostol use by midwives and doctors in Kenya. We had 6 quasi-experimental (before and after intervention) impact evaluations. The majority (56.7%) were however observational studies on the burden of unsafe abortion and practices of PAC. Detailed results are displayed in Table 1.
The main lessons learned from this review included: 1) Factors limiting the utilization of PAC services include; inadequate knowledge, high cost, less
Figure 2. Results of search.
Table 1. Major results of the review of literature on PAC in SSA from 2000-2018. Arranged in order of decreasing strength of evidence and then chronologically.
Abbreviations: MWs: Midwives, HCPs: Health Care Providers, MDs: Medical Doctors, IUD: Intrauterine device, RCT: Randomized Controlled Trial, MVA: Manual Vacuum Aspiration, HF: Health Facility, OCP: Oral Contraceptive Pill, LARCs: Long Acting Reversible Contraceptives.
adolescent-friendly services and fear of side effects of modern FP . 2) Abortion still represents a high burden in most countries of SSA   . 3) Hemorrhage, sepsis and maternal death are the major post abortion complications   . 4) Misoprostol and MVA have comparable efficiency and safety in PAC, especially in the first trimester . 5) Trained mid-level health cadres and physicians produce comparable results in the use of misoprostol and MVA in uncomplicated abortion care  . 6) There is increase uptake of modern contraception if PAC counselling and FP are available and offered immediately in the same room where emergency PAC was carried out before patient leaves the ward  . 7) The training of HCPs on quality PAC, husband authorization and constant availability of FP method mix improves significantly the uptake of modern contraception, especially LARCs    .
Worldwide, countries are classified into six categories according to the degree of restriction of their abortion laws . Articles reviewed represented all these categories as follows: Category 1, where abortion is prohibited was represented by Senegal . Category 2, where abortion is legal only to save the woman’s life was represented by Nigeria, Somalia, Tanzania and Uganda      . Category 3, where abortion is legal only to save the woman’s life and preserve her physical health was represented by Burkina Faso, Cameroon (including case of rape), Ethiopia, Kenya, Rwanda and Togo      . Category 4, where abortion is authorized to save the woman’s life and preserve her physical and mental health was represented by Ghana, Mozambique and Sierra Leone    . Category 5, where abortion is authorized to save the woman’s life, preserves her physical and mental health and on economic grounds was represented by Zambia  . Finally, category 6 where there are no restrictions to safe abortion upon request represented by South Africa   .
Countries with restrictive abortion laws, such as Cameroon and Nigeria have highest unsafe abortion burden . Hospital studies in Nigeria reported a specific mortality rate due to abortions of 11.5%, with case fatality rates as high as 9%  . Similar in Cameroon, unsafe abortions contributed to 24.2% of MMR as well as a high case fatality rate of 2.1%  .
Training of HCPs is known to improve the uptake of PAC services. According to an IPAS evaluation study in five SSA countries showed that the factors associated with increased uptake of PAC contraception were; young maternal age, availability of commodities, training of HCPs and cost    . From our study, we found that the main complications of unsafe abortion were similar in SSA countries. These include; incomplete abortion, severe bleeding and infection     . Similarly, PAC-FP uptake was boosted by the availability of a separate evacuation room and immediate provision of method mix contraception prior to discharged from the HF    . This is a rare practice in Cameroon, where often the two services are separate.
To fight against these complications of unsafe abortion, task shifting is crucial in low resource settings as SSA. Well trained mid-level health cadres in SSA were found to have comparable acceptability, safety and effectiveness to physicians in the management of incomplete first trimester abortions   . They were found to use equally either misoprostol or MVA in treatment and this is in line with the WHO recommendations . This task shifting will relieve physicians, reduce delay to HF and PAC and thus reduce complications and cost . However, in Cameroon, midlevel cadres are hardly authorized to manage emergency PAC.
The use of Misoprostol or MVA in the management of first trimester incomplete abortion and in medical abortion, had similar safety and effectiveness outcomes   . As seen above, these two methods can be handled easily by all trained health personnel. Availing these two commodities is thus of utmost importance in all HF and to all trained HCPs in order to meet the needs of patients irrespective of their means and geographical location in the country     . In Cameroon, misoprostol is seldom available to practitioners at all levels of care.
The strengths of our study reside in a detailed review of literature on PAC from five databases. The study designs varied from observational through randomized controlled trials to systematic reviews, representing 18 countries from all the four sub-regions of SSA. Mindful of the similarity in context of SSA, successful PAC service models from other SSA countries could be generalized in Cameroon. However, the main limitation is selection bias, since we retained mostly articles from countries with successful approaches of PAC services. Equally, we did not include studies published in other languages such as French, since we had enough articles in English. Finally, we did not explore in detail, the community component of PAC in this study.
In conclusion, abortion remains a major health problem in Cameroon and in SSA countries where safe abortion is authorized only under restrictive conditions leading to severe maternal complications. Though the practice of quality accessible PAC has been well codified by WHO and FIGO, these norms are diversely and seldom applied in SSA countries especially Cameroon. Though efforts have been made to improve the quality and access to PAC in Cameroon, much still has to be done. Conscious of the fact that the legalization of abortion might need a long time to change, advocacy towards less restrictive abortion laws in the country must be intensified. We recommend to the Society of Gynecologists and Obstetricians of Cameroon (SOGOC) and the Ministry of Health to improve access to quality PAC by task shifting to trained mid-level cadres and ensure regular supply of PAC commodities in the country.
We are immensely grateful to the Institute of Tropical Medicine (ITM)— Antwerpen, Belgium for their training and technical support. We equally wish to thank the Belgian Development Cooperation (DGD) for offering us the financial assistance and enabling environment that permitted us to realize this work.
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