Approximately 73 million induced abortions are performed each year worldwide [1] , and 13% of deaths in pregnancy are due to unsafe abortion [2] . In countries where abortion is legal, complications are rare. Most of these deaths occur in countries where abortion is highly restricted or illegal. In developing regions, 220 women die for every 100,000 unsafe abortions [3] . One third of all unsafe abortions were carried out in the most dangerous conditions, i.e. by people with inadequate training in this field and using dangerous and invasive methods [4] . In Togo in 2018, according to DHIS2 data, 8933 cases of abortion were recorded, of which 1700 were voluntary terminations of pregnancy [5] , and abortion-related complications accounted for 16.9% of maternal deaths [6] . The components common to all aspects of reproductive health include family planning (FP) and post-abortion care (PAC). Despite the availability of these measures, we are still witnessing an upsurge in the number of cases of induced abortion in gynaecology and obstetrics clinics, not to mention the complications that can sometimes result in death. The way in which complications of abortion are managed has evolved, helping to reduce maternal mortality due to abortion. From digital curage and curettage under local anaesthetic or sedation, we have moved on to manual intra-uterine aspiration under local anaesthetic or even simple medical treatment: this has improved the quality of care and services. The length of hospitalisation has been reduced from a few days to a few hours, making it possible to provide outpatient care [7] . Studies on abortion and its complications [8] - [11] have been carried out in Togo, but not specifically on induced abortion and its complications. In order to take stock of the cases of complications of induced abortion received and their management at the gynaecology-obstetrics clinic of the Sylvanus Olympio University Hospital Center (CHU-SO) in Lome, we initiated this study, the general aim of which is to describe the management of complications of induced abortion at the gynaecology-obstetrics clinic of the CHU-SO in Lome.

This is a descriptive cross-sectional study conducted among patients received at the Gynaecology-Obstetrics clinic of the CHU-SO of Lome between 1st August 2017 and 31 July 2022 (5 years) for complications of induced abortion. The records of patients who presented complications related to induced abortion during our study period were included. Our sampling was exhaustive and concerned patients who met our inclusion criteria. The variables studied were epidemiological, clinical and therapeutic. The data were processed and analysed using Excel and Epi info version 7.2 software. The results were considered significant for a p value < 0.05. Patients’ anonymity was preserved. An agreement of the ethical committee and an authorization N˚1078/2022/MSHPAUS/CHU-SO/DIR/DRH/SERV.PERS. of the Direction of the CHU-SO were also obtained.

Operational definitions

Limitations of the study: The sociocultural stigma surrounding abortion. Indeed, voluntary termination of pregnancy is not permitted in the country. As a result, there is a shortage of cases. The only patients we received were those who had complications, and some of these would probably have died from abortion complications before arriving at the CHUSO, the national referral center or would have been cared for in other health facilities. But this study will have had the merit of highlighting the various complications of abortion, and will open the way to multicentre studies.

Induced abortions accounted for 20.2% of all abortions received at the Gynaecology-Obstetrics clinic at the CHU SO. This result is almost similar to that reported by Diallo et al. [12] in Guinea Conakry in 2016, which was 17.2%. This non-negligible frequency of induced abortion in our series could be explained by various reasons, including patients’ lack of knowledge or prejudice about contraceptive methods, the fact that voluntary interruption of pregnancy is not legalised in Togo, and above all fear of reprisals and rejection by parents (fear of parents: 35.7%) or society (pregnancy outside marriage is considered a sin or a family dishonour). The mean age of the patients was 23.06 ± 5.87 years, with extremes of 15 and 42 years. Essie et al. [13] in 2020 in Brazzaville reported an average age of 25 ±6.6 years. Young women are more prone to induced abortion. This may be due to their high fertility rate, and also to a lack of sex education, sex being a taboo subject in our society. Most of the time, we hesitate to talk about it within the family. It’s true that school curricula now include sex education, but we don’t think that’s enough. Haemorrhagic complications were in first place, with retained placental debris (68.6%). Laghzaoui [14] in Morocco reported trophoblastic retention (91.3%). Misoprostol is often used, and is a source of incomplete abortion and haemorrhage [15] . In addition, abortions in developing countries are carried out under dangerous conditions [2] . In Togo, MVA is available in most health facilities, mainly to treat haemorrhagic complications of incomplete abortion and thus prevent women dying as a result of abortion. Contraceptive products are also available free of charge to prevent unwanted pregnancies. Infectious complications were dominated by endometritis (22.9%), followed by pelviperitonitis in 10% of cases. Uterine perforation was recorded in 10% of cases. Diallo et al. [12] reported 25% of cases of endometritis. Also, endo-uterine manoeuvres performed in septic conditions are most at risk of infectious complications. According to the WHO, restrictions do not reduce recourse to abortion, but probably increase the number of women seeking abortions by illegal and unsafe means, in the worst safety conditions, by incompetent people using dangerous and invasive methods [16] . In our case, toxic substances (potash and lemon, potash and ‘Guinness’, or bleach solution) and foreign bodies (cassava stems or other) were used in 14.3% and 7.1% of cases respectively. MVA was performed in 40% of patients and laparotomy in 11.4%. These results are similar to those of Diallo et al. [16] who reported 48.21% of cases of MVA compared with 10.71% of cases of laparotomy. In fact, endo uterine manoeuvres are more likely to cause traumatic lesions, if the technique is not properly applied, which may then require laparotomy to repair them. In 7.1% of cases, patients underwent hysterorrhaphy; hysterectomy was performed in 1.4% of patients. The case fatality rate in our study was 8.6%. Mukendi et al. [17] in the DRC in 2024 reported a hysterectomy rate of 12.5% and a hysterorrhaphy rate of 6.25%. Nationally, abortion-related deaths accounted for 16.9% of maternal deaths [6] . This lethality may be linked to delays in patient management. It has to be recognised that abortion, because of its stigmatising nature in our environment, patients after the act, whether by personal techniques (ranging from toxic products to manioc stems), or by the intervention of unqualified personnel, in an unsafe environment, would not have quickly decided to consult a doctor as soon as the first signs of complications appeared, thus causing a delay in treatment and hence the worsening of complications and then the death of some patients. In addition, socio-economic status (most of our patients were street vendors, and therefore on low incomes) could be blamed for this delay in treatment, since relatively young patients who are still financially dependent on their parents would not have been able to afford medical care without the support of a parent or guardian, who would often point an accusing finger at the perpetrators of this act, which in some conditions is considered a sin or an abominable crime [18] . In addition, the socio-cultural context (voluntary interruption of pregnancy is not permitted and the act of abortion is considered a criminal offence punishable by imprisonment [19] ) is also frowned upon by those around her.

Although illegal, induced abortion is still practised in Togo. This highlights the unmet need for contraception. With all the complications it causes, it constitutes a major factor in morbidity and mortality among women of reproductive age, compromising the obstetric future of patients. It therefore remains a real public health problem. The acquisition of a legal framework in our country is therefore necessary to avoid the sometimes fatal complications of abortion.