The epidemiology of incomplete abortion in South Africa Helen Rees, Judy Katzenellenbogen, Rosieda Shabodien, Rachel Jewkes, Sue Fawcus, James Mclntyre, Carl Lombard, Hanneke Truter and the National Incomplete Abortion Reference Group Objective. To describe the epidemiology of incomplete abortion (spontaneous miscarriage and illegally induced) in South Africa. Design. Multicentre, prospective, descriptive study. Setting. Fifty-six public hospitals in nine provinces (a stratified, random sample of all hospitals treating gynaecological emergencies). Patients. All women of gestation under 22 weeks who presented with incomplete abortion during the 2-week study period. Main outcome measures. Incidence of, morbidity associated with and mortality from incomplete abortion. Main results. An estimated 44 686 (95% Cl 35 633 - 53 709) women per year were admitted to South Africa's public hospitals with incomplete abortion. An estimated 425 (95% Cl 78 - 735) women die in public hospitais from complications of abortion. Fifteen per cent (95% Cl 13 - 18) of patients have severe morbidity while a further 19% (95% Cl 16 - 22) have moderate morbidity, as assessed by categories designed for the study which largely reflect infection. There were marked inter-provincial differences Reproductive Health Research Unit, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg Helen Rees, M6 BChir. MA, MRCGP James Mclntyre, Ma ss. MRCOG Centre for Epidemiological Research in Southern Africa, Medical Research Council, Tygerberg, W Cape Judy Katzenellenbogen, MSc (Med). BSc Hons, BSc (Occ Therl Rosieda shabodien, asc (PhysK)) Aachel Jewkes. 1'.16 ss, MSC, NlFPHM, MD Carl Lombard. PtlD Hanneke Truter, MSC Department of Obstetrics and Gynaecology, Groote Schuur Hospital, Cape Town Sue Fawcus. MA. Ma as. MRCOG The National Incomplete Abortion Reference Group's members come from each of the academic Departments of Obstetrics and Gynaecology in South Africa: Professor Hennie Cronje, University of the Orange Free State; Dr Paul Duminy, University of Stellenbosch; Professor Martin Marivate, MEDUNSA; Professor Jack Moodley, University of NataVMRC Pregnancy Hypertension Research Unit; Professor Bob Pattinson, University of Pretoria Volume 87 No.4 April1997 SAMJ and inter-age group differences in trimester of presentation and proportion of patients with appreciable morbidity, Conclusions. Incomplete abortions and, in particular, unsafe abortions are an important cause of mortality and morbidity in South Africa. The methods used in this study underestimate the true incidence for reasons that are discussed. A high priority should be given to the prevention of unsafe abortion. S Atr Med J 1997; 87: 432-437. Incomplete abortions, whether induced or spontaneous, are common reasons for admission to gynaecological wards in South Africa and many otner countries. Internationally it is estimated that approximately 20 million unsafe induced abortions are performed yearly, i.e. one unsafe abortion for every 10 pregnancies.' Induced abortion is one of the leading causes of maternal death worldwide, causing an estimated 13% of pregnancy-related deaths. For those women who survive, it is a major cause of maternal morbidity. It is estimated that in Africa, 20 - 35% of maternal deaths are attributable to unsafe abortion practices,2 In South Africa official estimates of the incidence of illegal abortion from the old Department of National Health and Population Development (DNHPD) range between 6 000 and 120 000 compared with 800 - 1 000 legal abortions.' Data on illegal abortion are notoriously difficult to collect because of the legal and cultural constraints that often Relatively little is known about the magnitude of health problems caused by induced abortions in Africa where, in most parts, the procedure is illegal. 8 The social anc cultural context in which abortions are performed is often not understood and little is known of the characteristics of women who resort to induced abortion. A major challenge is to identify the induced abortion cases in such an environment. Over the past few years the World Health Organisation has recognised that the high incidence of abortion and its sequelae is central to women's health. In order to research this sensitive health problem, the WHO has recommended that the focus of research move from 'illegal' or 'induced' abortions to 'unsafe abortions', i.e. the termination of pregnancy performed or treated by untrained or unskilled persons. 9 Although this definition emphasises· the effect of the procedures on women, causes of unsafe abortion include barriers to access to health services, such as poverty or geographical distance. Health facility records are one option for identifying cases of unsafe abortion, but tend to underestimate the rate. They may not include those patients who have uncompficated induced abortions, those who die before reaching the hospital, poorer women and those with poor access to services. The results therefore do not accurately refleCt what is happening in the population. Nevertheless, health facilities are.a convenient place to locate cases. Population-based surveys are an alternative, but result in substantial underreporting. In South Africa there have been no systematic attempts to investigate the epidemiology of incomplete abortion, unsafe/induced abortions or abortion-related deaths. Estimates are difficult to make because abortion is illegal,