Abortion-related morbidity and mortality in Sierra Leone: results from a 2021 cross-sectional study

Unsafe abortion remains a significant driver of maternal morbidity and mortality. We aimed to assess the severity of abortion complications among post-abortion care (PAC) clients in Sierra Leone and factors associated with more severe complications.

We applied the Prospective Morbidity Survey (PMS) among PAC patients and their providers in 142 facilities in Sierra Leone between August and October 2021. We administered a total of 522 patient PMS surveys and 513 provider PMS surveys. To assess post-abortion complication severity, we utilized a five-level severity classification system ranging from mild to maternal death. We conducted bivariate and multivariable tests to assess factors associated with the severity of complications. Dependent variables included demographic characteristics and delays to care reported by PAC patients.

Overall, 36% of PAC patients had mild complications, 30% moderate, 27% severe, and 8% near-miss. One person died. Many women experienced delays to care, particularly in realizing care was needed, deciding to seek care, and arriving at the health facility. Controlling for facility level, the risk of experiencing a severe or near-miss complication or death was not significantly associated with the patient's sociodemographic characteristics, except age and number of pregnancies; compared to adolescents 19 and under, PAC patients aged 20-24 had significantly lower risk of a severe/near-miss complication or death, while PAC patients with 2-4 pregnancies had significantly higher risk of a severe/near-miss complication or death compared to PAC patients experiencing their first pregnancy. Delays in accessing care were significantly associated with having more severe complications; patients were more likely to suffer the most severe complications if they had to wait longer than one hour to be attended to, or did not receive complete treatment within 12 h.

Compared to regional and global estimates, the burden of abortion-related complications in Sierra Leone is high. The recent effort to liberalize abortion law is promising; this potential legal reform must be paired with the expansion of safe abortion services to reduce abortion-related morbidity and mortality in the country. In the absence of legal change, our analysis also emphasizes the need to ensure PAC services are always free of cost, that women are aware of the availability and legality of PAC, and that facilities have the human and material resources needed to handle these cases.