Abstract

Objective: To study the epidemiological, clinical, therapeutic aspects and prognosis of clandestine induced abortions in northern Togo, from 2019 to 2025. Methodology: Retrospective descriptive study conducted from January 1, 2019 to August 31, 2025, including all cases of clandestine induced abortions managed at the Kara University Hospital. Results: The average age of the patients was 20 years, with ages ranging from 13 to 40 years. The majority were 20 years old (15.3%). Most were first-time mothers (68.1%). The patients were primarily schoolgirls (41.7%), homemakers (23.3%), and university students (11%). Those who were self-employed represented 23.3% of the patients. Those clandestine abortions occurred most frequently in October (12.8%), November (11%), and July (10.4%). Among the patients, 93.2% had no prior history of abortions. However, 5.2% had previously undergone an induced abortion. Clinically, the procedures were carried out either by the patients themselves (83.4%) or by third parties within a community (13.5%), often under unsanitary conditions. They sought medical attention within 72 hours of the procedure (60.7%). The methods used were traditional medications (75.5%), intrauterine maneuvers (12.9%), and misoprostol (11.6%). The reason for consultation was genital bleeding (62.6%), pelvic pain (27%), and fever (9.2%). The initial assessment upon admission noted hemorrhagic shock (44.2%), stable condition (31.3%), and septic shock (24.5%). The diagnoses made were incomplete abortion (76.7%), pelvic peritonitis (12.9%), and generalized acute peritonitis (10.4%). Treatment was medical (84.7%) and surgical (15.3%), with 24.8% requiring blood transfusion. Surgical treatment consisted of manual aspiration of the uterine contents (10.4%) and laparotomy (4.9%). Exploration revealed two cases of uterine perforation, two cases of uterine necrosis requiring hysterectomy, and one case of intestinal perforation. We recorded 15 maternal deaths (9.2%). Conclusion: This study shows the extent and impact of clandestine induced abortions among young people, requiring action at all levels of society to reduce this scourge.

Keywords

Clandestine Induced Abortions, Epidemiology, Clinical, Prognosis, Kara University Hospital

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1. Introduction

Abortion is defined as the expulsion of the product of conception before the 22^nd week of amenorrhea or when it weighs less than 500 grams [1]. It can be spontaneous or induced (or voluntary termination of pregnancy). Clandestine induced abortions constitute a major public health issue, particularly in countries where abortion is not legal. They are performed in an unlawful setting, often in precarious and unhygienic conditions, with a high risk of maternal morbidity and mortality [2] [3]. This illegal practice is engaged in by many young people, reflecting the weight of socio-cultural and religious taboos surrounding the issue of voluntary termination of pregnancy.

Worldwide, approximately 73 million induced abortions occur each year, with 97% taking place under aseptic conditions in developing countries. These abortions often result from unplanned or unintended pregnancies. So, 61% of unintended pregnancies end in induced abortion [4].

Africa and Latin America have the highest figures among women aged 15 to 49 due to legal restrictions: 27.9‰ in Ivory Coast, 22.9‰ in Burkina Faso, 17‰ in Senegal, 56‰ in the Democratic Republic of Congo, 33‰ in Nigeria, 5‰ in Niger, 7.21‰ in Morocco [5]-[8].

The most common complications are infection and hemorrhage. The infection may become systemic and progress to septicemia, a life-threatening condition that can be fatal.

According to a hospital-based study conducted in Mali, the infection was present in 50% of induced abortions compared to 13% in spontaneous abortions [9].

In Togo, induced abortion or voluntary termination of pregnancy is prohibited by law, which stipulates that maneuvers carried out with a view to the voluntary or induced termination of a pregnancy using remedies, substances, instruments or any object whatsoever constitute the offense of abortion [10].

National statistics are difficult to assess because most cases take place under unclear conditions. A study conducted in 2021 at the Kara University Hospital (CHU Kara) showed that clandestine induced abortion accounted for 11.33% of maternal deaths [11].

Given this situation and the scale of the problem in our communities, it seemed appropriate to conduct this study, the general objective of which is to study the epidemiological, clinical, therapeutic aspects and prognosis of clandestine induced abortions in northern Togo, from 2019 to 2025, and more specifically:

• to determine the frequency of clandestine induced abortions.

• to describe the socio-demographic characteristics of the patients.

• describe the clinical characteristics.

• to describe the therapeutic management of these cases of clandestine induced abortions.

2. Framework and Method of Study

2.1. Study Framework

Our study was conducted in the gynecology-obstetrics department of the Kara University Hospital, the terminal reference center for the northern region of Togo.

2.2. Study Method

2.2.1. Type and Period of Study

This was a series study of clandestine induced abortions received at the Kara University Hospital from January 1, 2019 to August 31, 2025, i.e. over a period of 6 years and 8 months.

2.2.2. Study Population

The population of our study consisted of all women of childbearing age who received gynecology-obstetrics consultations and obstetrics emergencies at the Kara University Hospital during the study period.

2.2.3. Sampling

1) Inclusion criteria

Included in this study were all patients diagnosed with clandestine induced abortion and who were treated at the Kara University Hospital during the study period.

2) Non-inclusion criterion

All patients diagnosed with spontaneous abortion or medical termination of pregnancy.

2.2.4. Variables Studied

The variables studied were related to:

• Socio-demographic aspects: age, residence, education level, profession;

• Epidemiological aspects: frequency, risk factors and history;

• Diagnostic aspects: reasons for consultation, physical signs, paraclinical signs;

• Therapeutic aspects: method of care;

• Prognostic aspects: immediate and short term.

2.2.5. Data Collection and Processing

A data collection form was created using Epi Info version 7 software. Data collection was extracted from hospital records, such as:

• patient charts;

• surgical registers;

Data entry, processing and analysis were performed using Word software for Windows 11 and Epi Info version 7. We designed the tables using Microsoft Office Excel 2016.

2.2.6. Ethical Considerations

The data collected was kept confidential and anonymous for the records of all patients. The study received approval from the relevant institutional review board at the Kara University Hospital.

3. Results

3.1. Frequency

The annual average of induced abortions was 24.4 per year. During the study period (2019 to 2025), 693 abortions were recorded, of which 163 were clandestine, representing 23.5% of all abortions.

3.2. Epidemiological Aspects

3.2.1. Age

The average age of the patients was 20 years, with a range from 13 to 40 years. The most common age group was 20 years (15.3%). Adolescents (13 to 19 years old) represented 48.5%, as shown in Table 1.

3.2.2. Occupation

The patients were primarily schoolgirls, homemakers, and university students in 41.7%, 23.3%, and 11% of cases, respectively (Table 2). Those who were self-employed represented 23.3% of the patients. Self-employment included hairdressing, sewing, retail, baking, and cooking.

3.2.3. Period of Clandestine Abortion

The practice of these clandestine abortions occurred in July (10.4%), November (11%), October (12.8%) and September (9.8%).

3.3. Clinical Aspects

3.3.1. Obstetric History

First-time mothers (those who have never given birth) represented 68.1%. Among the patients, 93.2% had no prior history of abortion. However, 5.2% had previously undergo an induced abortion.

3.3.2. Abortion Practices and Methods Used

Clinically, the procedures were carried out either by themselves (83.44%) or by a third parties within a community (13.5%), all under unsanitary conditions. The methods used to perform the abortions were traditional medicines (75.5%), intrauterine procedures (12.9%), and misoprostol (11.6%).

3.3.3. Consultation Deadlines and Reasons

Among them, 60.7% consulted within 72 hours of the procedure (Table 3).

3.3.4. Reasons for Consultation

The reasons for consultation were represented by genital bleeding (62.6%), pelvic pain (27%) and fever (9.2%) as shown in Table 4.

3.3.5. Physical Examination

The initial assessment upon entry to the Kara University Hospital noted hemorrhagic shock (44.2%), a stable condition (31.3%) and septic shock (24.5%).

The diagnoses made were: incomplete abortion (76.7%), pelvic peritonitis (12.9%), generalized acute peritonitis (10.4%) (Table 5).

3.4. Therapeutic Management

Among the patients, 84.7% received medical treatment and 15.3% received surgical treatment (Table 5).

24.8% of cases required blood transfusion. Surgical treatment consisted of manual aspiration of the uterine contents (10.4%) and laparotomy for generalized acute peritonitis (4.9%). Exploration after abdominal opening revealed two cases of uterine perforation, two cases of uterine necrosis extending to the hysteric regions requiring subtotal hysterectomy, and one case of intestinal perforation requiring excision and suturing of the small bowel loop.

3.5. Prediction

We recorded 15 cases of maternal deaths, representing a frequency of 9.2%.

Table 1. Distribution of patients across epidemiological elements.

Table 2. Distribution of patients according to profession.

Table 3. Distribution of patients according to consultation time.

Table 4. Distribution of patients according to reason for consultation.

Table 5. Distribution of patients according to clinical diagnosis and treatment.

4. Discussion

A major public health issue, the practice of abortion suffers from a serious problem of availability and quality of statistical data, which depends on the legal, cultural and religious framework in each society [3] [12].

In terms of epidemiological data, we recorded 163 cases of clandestine induced abortions, with a hospital frequency of 24.4 cases per year and representing 23.5% of all abortions. These figures are enormous, but they don’t tell the whole story. Beyond these numbers lie faces, suffering, individual distress, and deep, real reasons why these young women and teenagers resort to clandestine abortions. This figure underscores the urgent need for a health and legal policy to regulate this practice.

The average age in our study was 20 years, with the 13 - 19 age group being the most represented in 48.5% of cases. Our results are consistent with those of Iloki et al. in Brazzaville [13]. Diallo MH et al. found an average age of 23.2 years in Guinea, with a majority of patients aged 20-24 years in approximately 40% [8].

Adolescent girls are the most affected. They are a vulnerable population. They often try to postpone having their first child in order to finish their studies and find their first job. It is therefore desirable to promote girls’ school and academic education on responsible sexuality in our community, as recommended by many other African authors [3] [5] [8].

According to their socioeconomic background, students are the most affected by clandestine abortions. They typically undergo these abortions during school holidays (July, August) or at the beginning of the academic year (September, October). This vulnerable population often engages in risky sexual behaviors. To reduce these risky behaviors due to a lack of activities during the holidays, it would be advisable to introduce these students to income-generating activities during this time, thus making their vacations productive for these young women.

During adolescence, sexual desire and fantasies develop alongside the emergence of emotional and sexual relationships. At this time, a young girl discovers her body and is very sensitive to her body image. Her desire for emotional intimacy and romantic relationships increases. She becomes curious and eager to develop romantic and sexual relationships to explore her body, thus exposing herself to the risk of unintended pregnancies. At this stage, it is essential to create a trusting environment to discuss topics such as sexuality and contraception.

Takongmo et al. in Yaoundé also reported a predominance of students and pupils [14]. This could be linked to the high rate of unintended pregnancies resulting from the non-use and lack of knowledge of contraceptive methods. Indeed, in Togo, the contraceptive prevalence rate for modern methods remains low (21.4%), with 29.7% of the population experiencing unmet needs for family planning. It is important to implement integrated contraceptive care to optimize the provision of reproductive health and sexual rights services.

First-time mothers were the most represented, accounting for 68.1% of cases. This aligns with the findings of Iloki et al. in Congo Brazzaville, who reported a predominance of nulliparous women [13]. In our communities, where preconception counseling is almost nonexistent, a first pregnancy can be a source of anxiety, especially for young women, leading them to consider abortion. They often cite reasons such as continuing their studies or parental or biological father refusal.

Clinically, all patients were admitted to the university hospital in an emergency setting. Regarding abortion practices and methods, 83.44% of patients reported having performed the clandestine abortion themselves, and 13.5% reported having it done by a third party, all under unsanitary conditions. The methods used to perform the abortion were traditional medicines (75.5%), intrauterine maneuvers (12.9%), and the use of misoprostol (11.6%). The composition of this traditional medicine is often unknown. Our results are similar to those of Iloki et al., who reported the predominance of traditional decoctions in cases of clandestine abortions [13].

Sassor OPAT et al. had made the same observation in Côte d’Ivoire [15]. These are, unfortunately, dangerous practices, all of which are used to circumvent the legal rules in force that prohibit abortion.

Drabo et al. in Burkina Faso in 2022 reported a predominance of misoprostol in the practice of clandestine induced abortions which could be explained by the use of misoprostol as an emergency pill sold without a prescription in some African regions [16].

We recorded 76.7% of incomplete abortions; 12.9% of pelvic peritonitis and 10.4 % of generalized acute peritonitis.

Regarding management, 84.7% received medical treatment and 15.3% surgical treatment. Surgical treatment consisted of manual aspiration of the uterine contents (10.4%) and laparotomy for generalized acute peritonitis (4.9%). Upon opening the laparotomy, two cases of uterine perforation were noted, along with two cases of uterine necrosis extending to the hysteroscopic regions requiring hysterectomy, and one case of intestinal perforation requiring excision and suturing. Diallo MH had previously reported one case of subtotal hysterectomy, six cases of hysterorrhaphy, and four cases of suturing ileal lesions without resection [8].

Post-abortion outcomes were uncomplicated in 90.8% We recorded 15 cases, representing 9.2% of maternal deaths. In Benin, abortion accounts for 15% of maternal deaths despite the legalization of voluntary termination of pregnancy [2]. In the case series by Takongmo et al. in Yaoundé, the maternal mortality rate due to clandestine abortions was 15.60% [14], which is higher than ours. According to Elam-Evans et al., the maternal mortality rate due to clandestine abortions was 0.0006% in the United States [3]-[5] [7], which is much lower than ours. Our high mortality rates can be attributed to the lack of medical oversight of induced abortion due to our legislation, which is so restrictive that many women often resort to methods that jeopardize their lives. Illegal abortion is punishable by severe prison sentences in many other countries, such as Togo, Kenya, Nigeria, Senegal, and Uganda, where it is punishable by three (3) months to two (2) years and a fine [10] [17]. Unsafe abortion places a heavy burden on Togolese women. Reducing barriers to effective contraception and ensuring access to post-abortion care without the risk of legal repercussions could lessen the complications of unsafe abortion [16]-[19].

5. Conclusion

This study shows the extent and impact of clandestine induced abortions among young people and adolescent girls in our communities; who represent the next generation. In order to protect this vulnerable population in Togo, action must be taken at all levels of society. Targeted contraceptive education for adolescents and standardized post-abortion care protocols will be important.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References