Usual hospital care versus post-abortion care for women with unsafe abortion: a case control study from Sri Lanka

BACKGROUND: Good quality post-abortion-care (PAC) is essential to prevent death and long-term complications following unsafe abortion, especially in countries with restrictive abortion laws. We assessed the PAC given to women following an unsafe abortion, compared to the routine hospital care following spontaneous abortion or unintended pregnancy carried to term in Sri Lanka. METHODS: A case–control study was conducted in Sri Lanka among 171 cases following unsafe abortion, 638 controls following spontaneous abortion (SA-controls) and 600 women following delivery of an unintended pregnancy (TUP-controls) admitted to same hospitals during the same period. Care provided was assessed using interviewer-administered-questionnaires and in-depth-interviews at hospital discharge and in a sub-sample, at 6–8 weeks post-discharge. Differences in care were assessed using chi-square tests. RESULTS: Mean age of cases was 30.6 years (SD = 6.6); 21.1% were primis. 60.8% cases developed sepsis and 12.3% organ failure. Cases received timely, complete and safe emergency treatment with no difference to SA-controls (p > 0.05): removal of retained products of conception medically (14.6% cases versus 19.4% SA-controls) or surgically (73.7% versus 75.1%), within 24 hours of admission (63.5% versus 52.8%), under anaesthesia (84.1% versus 92.3%) and intravenous antibiotics (91.2% versus 31.0%). Despite this equitable treatment, cases were dissatisfied with their overall care during hospital stay, predominantly due to verbal harassment of health-care-providers on their abortion status (57.9% versus 19.3% SA-controls, p < 0.05). Ward doctors provided the best care to cases in all aspects, except compared to SA-controls in explaining women’s health status (60.2% versus 77.7%), and compared to TUP-controls in providing information on contraceptive methods (14% versus 24.3%), service availability (13.5% versus 24.7%) and assistance in decision-making on contraception (13.5% versus 21.3%). Ward-midwives contributed none to family-planning care of cases. At 6–8 weeks, 48.9% of cases were on contraceptive methods, predominantly short-term, compared to 85.3% of TUP-controls, predominantly long-term methods (p < 0.01). CONCLUSIONS: Despite equitable emergency treatment, care following unsafe abortion was deficient in post-abortion counselling, education and family planning services. Engagement of public-health staff for follow-up care was inadequate. Perceived dissatisfaction of overall care was owing to discrimination related to their abortion status.