Induced abortion, or voluntary termination of pregnancy (VTP), is a complex and sensitive issue that intersects with public health, human rights, ethics, and legislation. In certain countries, such as Côte d’Ivoire, abortion is legally restricted to cases with therapeutic indications only [1] .

This prohibition is the cause of clandestine induced abortions, which lead to numerous complications. Voluntary termination of pregnancy is a widespread phenomenon in Côte d’Ivoire, despite its illegal status [2] .

In Côte d’Ivoire, the prevalence of induced abortions is 42.5% [1] . Furthermore, there is no health Policy in place to improve the management of complications.

We report four cases of vaginal evisceration observed between 2016 and 2025 (one case in 2016, 2023, 2024, and 2025).

The objective is to present the complications involving uterine and intestinal perforations resulting from clandestine induced abortions at the University Hospital of Bouaké.

The study involved four patients aged 24, 27, 35, and 39 years. All of these patients were single and unemployed, with one being the mother of a 2-year-old child, one cohabiting with eight children, and the other two being nulliparous. They were admitted to the obstetrics and gynecology emergency department for vaginal evisceration following an intrauterine abortion procedure performed at local healthcare centers. The gestational age of the pregnancies was 14 and 16 weeks, respectively. Clinical examination revealed a transvaginal evisceration of the small intestine, which was either necrotic ( Figure 1 ), perforated multiple times ( Figures 2-3 ), or ligated ( Figure 4 ).

All the patients presented with acute generalized peritonitis and shock. A Laparotomy was indicated for all patients.

Intraoperative findings revealed both digestive and gynecological lesions:

-Digestive lesions: Small bowel perforation in all patients, and strangulation of a loop of the small intestine through a uterine body breach in two patients.

-Gynecological lesions: a destructive isthmic uterine wound in two cases ( Figure 6 ), and a clean uterine body wound in two cases ( Figure 5 ).

The management of the uterine lesions involved uterine suturing in two cases and hysterectomy in two cases. Regarding the intestinal lesions, a small bowel resection with ileostomy was performed in three patients, while one patient underwent resection with anastomosis.

The progression in the three patients with stomas was characterized by:

-Pariétal suppuration,

-Pariétal suppuration with covered evisceration followed by eventration and healing,

-A well-progressing stoma as well as the resection and anastomosis.

The average hospital stay was 7 days.

Stoma reversal was performed 6 weeks later for three patients, and 3 months later for one patient.

The restriction of induced abortions (IA) leads to clandestine abortions carried out under unhealthy and unsafe conditions. Indeed, these abortions are performed by unqualified individuals, which results in numerous disastrous complications, sometimes even death [3] [4] .

The patients were single and unemployed. According to some authors, these clandestine induced abortions are more common among adult single women compared to married women [2] [5] . This can be explained by the inability to assume parenthood for various reasons, including the fear of shame and dishonor. The single woman is more vulnerable to induced abortion due to the absence of a legal partner and the financial, or even psychological, support that they could have provided.

Transvaginal eviscerations have become increasingly frequent in our practice in Bouaké, with three cases observed in the past three years. Cases reported in the literature are typically isolated incidents [5] [6] . The general population is often illiterate and impoverished. The search for low-cost healthcare drives them to seek services from unqualified practitioners.

Due to the proximity of the digestive tract, its injury is very common in clandestine induced abortions [6] - [9] . Surgical treatment of digestive perforations is complex and costly. Some authors perform resection with stoma, as done for most of the patients in our study [5] [6] . The presence of a stoma affects body image, social integration, and psychological well-being, often leading to depression, and can also impact the individual’s economic position within society [6] [7] .

Small bowel resection typically involves removing more than 50% of the small intestine, resulting in short bowel syndrome, which is costly to manage. An anastomosis resection was performed in one patient. While this technique is highly beneficial, the high risk of fistula formation due to the infectious context of the cavity often leads some practitioners to opt for stoma creation [4] [5] .

Uterine perforations are frequent, and their treatment involves either suturing or hysterectomy, both of which have significant long-term implications for fertility. Treating infertility requires substantial resources, and most of these women lack the financial means for such treatments. The inability to have children due to induced abortions can sometimes lead to rejection within the household and by the family [6] .

In this study, there were no deaths ; however, the global mortality rate, especially in Côte d’Ivoire, remains high according to certain studies [2] [7] . Awareness, education, and access to effective contraceptive methods for all could reduce clandestine abortions and ultimately decrease mortality [10] .

Some recommendations to authorities and healthcare providers :

1-Legalize abortion and accompany it with pragmatic policies.

2-Empower women to make independent and autonomous decisions.

3-Involve, when appropriate, male partners in discussions about abortion.

Induced abortion remains highly prohibited in Côte d’Ivoire, leading to dangerous situations for women who have no other option but to resort to illegal and often hazardous practices.

Training and strengthening the capacity of healthcare providers to improve their professional skills, communication, and attitudes toward women seeking abortion services is essential.

Reducing barriers by providing effective contraceptive methods, accessible to all without discrimination, could significantly reduce the incidence of clandestine induced abortions.