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.

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].

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.