Introduction Ethiopia, an ancient country with a long history of independence- perhaps as long as the evolution of the homo sapiens- is also the seat of some of the world’s ancient civilizations in record. The Axumite, Lalibela and other early civilizations centered in Ethiopia have gradually declined over the succeeding centuries to be followed by hundreds of years of isolation, introversion and stagnation that has persisted to the modern era. Hence, this once great country and its peoples have missed on most of the dramatic changes of recent civilization including the numerous benefits of the industrial revolution of the eighteenth century. At the turn of the twentieth century, this once great civilization found itself among the world’s “backward” nations. The only significant exception was that its people have maintained their independence; an admirable, historic and astounding feat of great import to Ethiopians and people of African descent. This centuries old socioeconomic isolation and backwardness led to a poor state of health of its people without access to the benefits of modern medical amenities. Women’s health including their sexual and reproductive health (SRH) was and still is markedly poor; often compounded by gender bias and harmful traditional practices. This has led to a very high rate of maternal mortality and morbidity that has persisted to the present day. Modern nation building initiated during the reign of Emperor Theodros and intensified by Emperor Menelik at the turn of the twentieth century gradually led to the introduction of Ethiopia to modern medicine; a process that has yet to reach the whole of the country. Although some expatriate medical practitioners have come to Ethiopia beginning from the sixteenth century, they have often catered for the royal families of the times, their entourage and the populace in the immediate vicinity. Access to organized modern health care for the population began with the introduction of the first hospital in Ethiopia, the Russian Red Cross Hospital (predecessor of the current Menelik II Hospital in Addis) in 19061. Although detailed information could not be found, it can be assumed that some form of obstetric-gynecologic care was part of the medical care provided at this hospital. Expatriate physicians provided some form of modern health care mostly to the populace of Addis Ababa during the first half of the twentieth century, including the five years of Italian occupation. The evolution of modern maternity care in Ethiopia can be reviewed under three phases which include the early decades of the twentieth century, when maternity departments and hospitals were established in the country (mostly in Addis Ababa). This period included the first eight decades of the twentieth century. The establishment of the Graduate Program of the Department of Obstetrics and Gynecology of the Faculty of Medicine, Addis Ababa University was twenty seven years ago in 1980 2. It was a turning point in the expanded provision of specialized maternity care in Ethiopia. It has led to the increase in the number of gynecologists in the country from the handful of expatriates and foreign trained Ethiopians working mostly in Addis Ababa at the time, to the hundreds working in the capital as well as in the various parts of the country today. Establishment of the Ethiopian Society of Obstetricians and Gynecologists (ESOG) in 1992 marks the third important milestone in specialty level SRH services, as it signaled the initiation of an organized, public health commitment to take up the challenge of improving the SRH status of the peoples of Ethiopia. It is heartening to see that this third and most important phase has gained momentum over the years as ESOG prepares to go forward with new initiatives to achieve its vision and missions.

Introduction About 2% of all pregnancies are ectopic, accounting for 10% of all pregnancy related deaths (1). More than 95% of ectopic pregnancies occur within the fallopian tubes (2). Abdominal pregnancy, a rare variety of ectopic pregnancy, is defined as an intra-peritoneal implantation that is exclusive of tubal, ovarian or intra-ligamentous implantation. The world-wide incidence ranges from 1:3300 to 1:10200 births and accounts for 1 to 4% of all ectopic pregnancies (3-7). Even more uncommonly does it reach an advanced stage of gestation, and a viable abdominal pregnancy with a successful outcome is a rare event (8-10). The condition is associated with very high maternal mortality, with reported rates of 0.5 to 18% (1). The major cause for this is massive hemorrhage which may occur during pregnancy, during surgery or in the post operative period. Similarly, the condition is associated with very high perinatal mortality rate of about 95% (1, 11). This is attributed to preterm deliveries resulting from active intervention, done in the majority of the cases as soon as the diagnosis is made. Diagnosis of abdominal pregnancy is difficult and often missed (1, 4). Symptoms and signs such as abdominal pain, gastro-intestinal symptoms, painful fetal movements, abnormal presentations, uneffaced and displaced cervix, vaginal bleeding, palpation of pelvic mass distinct from the uterus, inability to stimulate uterine contraction with oxytocin, are considered suggestive evidences of an abdominal pregnancy (3, 4). This paper reports a 35 years old gravida two para one mother who was 7 months pregnant and presented with sign and symptoms of intestinal obstruction and later diagnosed to have an advanced abdominal pregnancy which was managed at Ambo hospital. Case Report The patient was 35 years old gravida two para one mother from Gindeberet, West Shoa, who was amenorrhic for seven months with abdominal pain and failure to pass feces for one week with subsequent failure to pass flatus and vomiting of ingested material since one day prior to her presentation to Ambo Hospital, West Shoa, Ethiopia. Initially she was seen at the surgical department and was admitted as a case of intestinal obstruction in the third trimester of pregnancy. After further work up she was transferred to the obstetric department with the diagnosis of advanced abdominal pregnancy. She had no antenatal follow-up. She said that pregnancy was uneventful before the onset of the above symptoms. She used to feel fetal movements. She is married and a farmer. During examination, she was acutely sick looking. Vital signs were stable with blood pressure of 120/60 mmHg, pulse rate of 88/ min, and a temperature of 36.6 degrees Celsius. On abdominal examination, it was grossly distended and difficult to appreciate fetal parts and presentation. Abdomen was diffusely tender with hyperactive bowel sounds. Fetal heart sounds were heard. On pelvic assessment, cervix was closed uneffaced, and it was pushed anteriorly. There was a soft bulge at posterior cul-de-sac. Hematocrit was 30% and on abdominal ultrasound examination there was an alive fetus and it was difficult to measure BPD because of irregular contour of the skull bones. There was scanty amount of amniotic fluid. There was small sized uterus posterior to urinary bladder. Just posterior to the uterus, there was a homogenous echogenic mass occupying the posterior cul-de-sac and which looked like the placenta (Fig.1). With the assessment of an abdominal pregnancy and intestinal obstruction laparotomy was performed, and the intra-operative finding was that there were grossly distended small bowel loops. When the small intestine was exposed, there was an intact gestational sac free in the peritoneal cavity extending to the posterior cul-de-sac and there was a viable fetus inside the sac. The urinary bladder was edematous and non pregnant size uterus was found just posterior to bladder. The fallopian tubes and both ovaries were intact but edematous. What we did was that we opened the gestational sac and clear liquor came out. A female fetus weighing 900g was extracted. The placenta was found in the cul-de-sac and it had attachments to the posterior wall of uterus, pelvic peritoneum of posterior cul-de-sac and part of anterior wall of rectum. It was removed completely with the gestational sac. Peritoneal cavity was lavaged with copious amount of saline. Post operative hematocrit was 20% and the patient was put on IV triple antibiotics and she was supplemented with iron tablets for 3 months. She was discharged on the sixth post operative day with improvement and was appointed to regular Gynecologic OPD but she was lost to follow up. On examination of the fetus there were deformities over the head and both lower extremities. She was put under radiant warmer, oxygen through nasal catheter was given, and NG tube was inserted for feeding. Umbilical catheterization was attempted by the pediatrician but failed. The fetus was able to survive for 36 hours then expired (Fig.2). Fig.1: Abdominal ultrasound showing an empty uterus separate from the gestational sac and the deformed fetal skull. Fig.2: The fetus from abdominal pregnancy with multiple compression deformities Discussion The incidence of abdominal pregnancy appears to be increasing in both developed and developing countries (11). In the former, increasing use of assisted reproductive technology with embryo transfer has been associated with increasing numbers of heterotopic pregnancies (12-15). In developing countries, particularly in the rural areas, a high incidence of abdominal pregnancies is reported, presumably due to restriction of human resources and diagnostic facilities, and poor utilization of medical care by pregnant women (16-18). Under both circumstances, some undiagnosed tubal pregnancies may abort into the peritoneal cavity, implant and continue into advanced abdominal pregnancies. The clinical presentation depends on the gestational age: in the first trimester, symptoms are similar to those of tubal ectopic pregnancies. In the second or third trimesters, the diagnosis may be suspected because of an abnormal fetal presentation, signs and symptoms of intestinal obstruction, displaced uterine cervix or easily palpable fetal parts (6). In our case, the patient presented with signs and symptoms of intestinal obstruction in the third trimester of pregnancy. To diagnose an abdominal pregnancy on ultrasound, one should try to delineate the uterus as a separate structure from the fetus and placenta. Sometimes even under best circumstances, and using sonography, the diagnosis is often missed (6, 19-21). On ultrasound examination of our case, it was possible to demonstrate intra-abdominal pregnancy with placental implantation outside a non pregnant size uterus. CT scan and MRI have been used successfully to complement sonography in making an accurate diagnosis of abdominal pregnancy (1, 22-25). Once the diagnosis is made, optimal management requires careful evaluation and planning. If it is diagnosed in the first trimester or in early second trimester, the management is surgical intervention without delay. However, due to late presentation of cases, the condition may remain undiagnosed until viable stage of gestation, i.e. after 24 weeks of gestation. The major questions raised in such cases are related to the timing and mode of delivery. Although no consensus exists on the issue, a conservative approach is proposed in the absence of fetal gross malformation, placental implantation remote from the upper abdomen, good maternal condition, and close management in a tertiary care hospital (7). In our case, conservative approach had no place because she presented with signs and symptoms of intestinal obstruction. Similarly, no consensus exists on the management of the placenta and each case is managed on an individual bases according to intra-operative findings. Regardless of gestational age, removal of placenta can result in hemorrhage. Unless the entire blood supply of placenta can be ligated, it is best to leave the placenta in situ and then follow the patient with serial B-hCG levels and sonography [6, 24, 28]. In the present case, the implantation site was in the lower part of abdomen at cul-de-sac. The major arterial supply of the placenta was identified and was ligated. The whole part of placenta with gestational sac was successfully removed. Since the patient came from remote area, it would have been difficult to leave the placenta behind and to have regular follow-up, especially with the unavailability of B-hCG determination. Some have advocated the use of methotrexate with varying degree of success. Risks associated with leaving the placenta in situ include bowel obstruction, fistula formation and sepsis as the placental tissue degenerates (1). References 1. Martin JNJr, Sessums JK, Martin RW, et al: Abdominal pregnancy: Current concepts of management. Obstet Gynecol 1988;71(4):549-57. 2. Neiger R, Welden K, Means N: Intramural pregnancy in a cesarean section scar. A case report. J Reprod Med 1998; 43(11):999-1001. 3. Bayless RB: Non-tubal ectopic pregnancy. Clin Obstet Gynecol 1987; 30(1):191-4. 4. Pasternoster DM, Santarossa C: Primary abdominal pregnancy. A case report. Ninerva Ginecol 1999;51(6):251-3. 5. Morita R, Tsusumi O, Kuramochi K, et al: Successful laparoscopic management of primary abdominal pregnancy. Hum Reprod 1996; 11(11):2546-7. 6. White RG: Advanced abdominal pregnancy, a review of 23 cases. Irn J Med Sci 1989; 158(4):77-8. 7. Geerinckx KR, Baekelandt M, Dauwe D, et al: An advanced abdominal twin gestation after primary infertility and after tubal pregnancy. Eur J Obstet Gynecol Reprod Biol 1987; 26(3):283-8. 8. Sapuri M, Klufio C: A case of advanced viable extra uterine pregnancy. PNG Med J 1997; 40(1):44-7. 9. Deneke F: Advanced abdominal pregnancy in an Ethiopian mother: A case report. East Afr Med J 1997; 74(8):535-6. 10. Bachorz T, Waszynski E: Abdominal pregnancy at term Fetus-Ginekol Pol 1994; 65(9):518-21. 11. Crabtree KE, Collet B, Kilpatrick SJ: Puerperal presentation of a living abdominal pregnancy. Obstet Gynecol 1994; 84(4pt2):646-8. 12. Scheiber MD, Cedars MI: Successful management of a heterotopic abdominal pregnancy following embryo transfer with cryopreserved-thawed embryos. Hum Reprod 1999; 14(5):1375-7. 13. Deshpande N, Mathers A, Acharya U: Broad ligament twin pregnancy following in-vitro fertilization. Hum Reprod 1999; 14(3):852-4. 14. Fisch B, Peled Y, Kaplan B, et al: Abdominal pregnancy following in-vitro fertilization in a patient with previous bilateral salpingectomy. Obstet Gynecol 1996; 88(4pt2):642-3. 15. Bassil S, Pouly JL, Canis M, et al: Advanced heterotopic pregnancy after in-vitro fertilization and embryo transfer, with survival of both the babies and the mother. Hum Reprod 1991; 6(7):1008-10. 16. Zvandasara P: Advanced extrauterine pregnancy. Cent Afr J Med 1995; 41(1):28-34. 17. Bugalho A, Carlomagno G: Advanced non-tubal ectopic pregnancy at the "Hospital Central" of Maputo (Mozambique).Clin Exp Obstet Gynecol 1989; 16(4):103-5. 18. Alto W: Is there a greater incidence of abdominal pregnancy in developing countries? Report of four cases. Med J Aust 1989; 151(7):412-4. 19. Moonen-Delarue MW, Haest JW: Ectopic pregnancy three times in line of which two abdominal pregnancies. Eur J Obstet Gynecol Reprod Biol 1996; 66(1):87-8. 20. El-Kareh A, Beddoe AM, Brown BL: Advanced abdominal pregnancy complicated by bilateral ureteral obstruction. A case report. J Reprod Med 1993; 38(11):900-2. 21. Costa SD, Presley J, Bastert G: Advanced abdominal pregnancy. Obstet Gynecol Surv 1991; 46(8):515-25. 22. Hall JM, Manning N, Moore NR, et al: Antenatal diagnosis of a late abdominal pregnancy using ultrasound and magnetic resonance imaging: a case report of successful outcome. Ultrasound Obstet Gynecol 1996; 7(4):289-92. 23. Qureshi RN, Chaudnuary N, Rizvi I, et al: Feticide followed by successful removal of pregnancy products in early abdominal pregnancy. J Obstet Gynecol 1995; 21(1):13-16. 24. Spanta R, Roffman LE, Grissom TJ, et al: Abdominal pregnancy: magnetic resonance identification with ultrasonographic follow-up of placental involution. Am J Obstet Gynecol 1987; 157(4pt1):887-9. 25. Wagner A, Burchardt AJ: MR imaging in advanced abdominal pregnancy. A case report of fetal death. Acta Radiol 1995; 36(2):193-5. 26. Shumway JB, Greenspoon JS, Khouzami AN, et al: Amniotic fluid alpha-fetoprotein (AFAFP) and maternal serum alpha fetoprotein (MSAFP) in abdominal pregnancies: correlation with extent and site of placental implantation and clinical implications. J Mat Fet Med 1996;5(3):120-3. 27. Yu S, Pennisi JA, Moukhtar M, et al: Placental abruption in association with advanced abdominal pregnancy. A case report. J Reprod Med 1995;40(10):731-5. 28. Bajo JM, Garcia-Frutos A, Huertas MA: Sonographic follow-up of a placenta left in-situ after delivery of the fetus in an abdominal pregnancy. Ultrasound Obstet Gynecol 1996;7(4):285-8.

Introduction Unsafe abortion is a preventable tragedy and is one of the neglected problems of heath care in developing countries including Ethiopia. Annually, an estimated 25,000 women die of pregnancy and delivery complications in Ethiopia (1) and the maternal mortality ratio (MMR) was estimated to be 871 per100, 000 live births (2). Unsafe abortion has a significant contribution to this high MMR. A community-based study conducted in Addis Ababa in 1985 revealed that unsafe abortion was the commonest cause of maternal death (3). Furthermore, subsequent hospital-based studies in Addis Ababa, reported that abortion accounted for 22.2% and 52.2% of all maternal deaths (4,5). A report from the Ministry of Health also showed that abortion was the leading cause of hospital admission for women in 1994/95, and it was the second most frequent cause of death next to tuberculosis in the same year (6). These findings indicated that illegal and unsafe abortion was a serious public health problem. Although after the International Conference on Population and Development (ICPD) (7), the abortion issue received a lot of attention mainly because of its serious health consequences. However, lack of reliable information or shortage of necessary data on this problem has hampered a number of activities that would have helped in ameliorating the situation. The objective of the study was to describe the magnitude of abortion, the socio-demographic characteristics of women with unsafe abortion and the complications and outcome of abortion in a representative sample of health facilities. Moreover, identifying the factors and reasons associated with unsafe abortion as well as conducting cost analysis using the modified Delphi technique was also the focus of this study. Subjects and Methods This is a cross-sectional study, which was conducted from July to December 2000 in 15 hospitals in 9 regions of the country on the magnitude and complications of abortion. Hospitals from two regions (Benshangul-Gumuz and Harari) were invited to participate but latter failed to do so. However, the population under study constituted over 98 percent of the population of the country (7). A pre-tested questionnaire with major socio-demographic characteristics, reproductive health history, contraceptive knowledge, attitude and use, reasons and conditions for induced abortion, history of present illness, complications and outcome of abortion was administered. A checklist was also prepared on physical examination, laboratory and other investigations, drugs, and procedures undertaken and costs for the care of the patient. Trained obstetricians and gynecologists working in the selected hospitals administered the questionnaire and checklist after receiving consent from study subjects. In hospitals where there are no specialists, general medical practitioners were identified to carry out the survey. For cost analysis, the modified Delphi technique was adopted for this particular survey as there were no standard payments for services, and costs for medications/drugs vary from institution to institution in the public and private sectors. A panel of experts was established to develop models of resource-use addressing three clinical conditions of unsafe abortion (mild, moderate and severe) detailed in Table 1. Members of the panel comprised of obstetricians/gynecologists, general medical practitioners, midwives and nurse anesthetists at federal and regional levels. By applying this consensus building qualitative method, it was possible to estimate the direct medical cost that has been incurred by facilities surveyed. The application of the modified Delphi technique required identified experts to be communicated more than once (not more than three times) on this issue. Moderators collected and compiled information from the panel and communicated back results for consensus. Communication was pursued through mail or hand delivery in order to maintain anonymity of members of the panel to avoid peer pressure and senior staff influence on the group. All institutions which participated in the study were included in the study after a written institutions consent to participate was secured after which the Ethiopian Science and Technology Commission provided the ethical clearance for the study Results A total of 1075 cases of abortion were included in the study. Table 2 shows the socio-demographic characteristics of the patients who presented with incomplete abortion in health facilities. Women in the age group 20-29 accounted for 58.3 percent of all cases. Fifty three percent were housewives; sixty percent were married, while the rest were single. Students accounted for 14.6 percent of all cases. Although the majority of Ethiopian women are illiterate, a high proportion of the patients had educational status of primary school or higher. The majority are Orthodox Christians. Amhara and Oromo accounted for 48 percent and 20 percent of all cases, respectively. The distribution of patients by region shows that the majority were from Amhara (27.6 %), Addis Ababa (25 %), Tigray (15.9 %), and Oromiya (13.2 %). The leading institutions that reported the highest number of abortion cases were Gondar (16.8 %), Mekele (15.7 %), Ghandi Memorial (12.8 %), and Yekatit 12 (10.1 %) Hospitals. The reproductive characteristics of the study population are detailed in Table 3. One third of the respondents had no previous pregnancy and delivery experiences. Three fourth had no previous history of abortion and ninety percent had no history of induced abortion. The distribution of women by type of abortion revealed that 800 women (74.4%) had spontaneous abortion and 275 (25.6%) had induced abortion. Looking at the contraceptive knowledge and use profile of the women, one could note the wide discrepancy in the knowledge and use rate of modern methods of contraception. Eighty six percent revealed knowledge of contraception whereas 46.3 % expressed use and 24.7 % revealed use of a method of contraception prior to the current abortion. Further, more than 50% of all the pregnancies were either unwanted and/or unplanned. Three hundred seventy seven (35.3%) were unplanned, and 525 (49.1%) were unwanted. Non-use of method was responsible for 78% of pregnancies; 19% women reported that unwanted pregnancy occurred due to contraceptive failure, which has important implications for the provision of appropriate family planning services. Partner decision alone as a reason for termination accounted for 9.3% of all cases, and rape accounted only for 3% of all pregnancies that ended in unsafe abortion, which was 2.5% of all the reasons for interfering with pregnancies (Table 4). Fifty eight percent of all cases terminated the current pregnancy either by seeking the help of untrained personnel or themselves with no assistance. Of those women with induced abortion, two hundred fifty nine patients identified the person who initiated the abortion. Many categories of health workers were involved in providing termination service of which health assistants rank first and pharmacists rank last. Five hundred and forty (65%) of all the interviewees and 181 (70%) of women with induced abortion were aware that abortion was associated with such grave complications like death, bleeding, genital tract injury, infertility and HIV infection as possible risks. The reasons for hospital visits are shown in Table 5. A patient may present with more than one symptom. The most frequent reason for hospital visit was vaginal bleeding (89.3%, n=960), abdominal pain (43.7%, n= 470), abortion (17.9%, n=192), fever (12.3%, n=132), vaginal discharge (10.6%, n=114), and others (4.5%, n=49). The most common method of evacuation was evacuation and curettage (83.6%) and MVA was employed to a much lesser extent (11%). The distributions of complications of induced abortion are depicted in Table 6. The major categories of complications identified were infection, genital tract injuries and foreign bodies in the genital tract, which accounted for 28.4%, 12%, 1.6%, respectively. A total of 13 deaths were reported, which makes the overall procedure related death of 1,209 per 100,000 abortions. Comparison of cases with induced abortion with the spontaneous group showed that women who presented with induced abortion were younger than those who presented with spontaneous abortion. The mean age of women with induced abortion was 22.9 ±5 years whereas the mean age of women with spontaneous abortion was 26.3 ±6 years. The difference was statistically significant (p < 0.00001). The mean parity of women with induced abortion was 0.8± 1, and that of women who presented with spontaneous abortion 2.0 ±2. The difference was statistically significant (p<0.00001). The odds of dying from induced abortion are more than four times higher in the induced group compared to the spontaneous group (Table 6). The same Table indicated that more women with induced abortion were from urban areas than from rural areas. There was no statistically significant difference between induced and spontaneous group in the incidence of rape. The panel of experts after considering the different clinical scenarios presented to it by the moderators, and taking into account the resources used to treat incomplete abortion by category of severity (Table 7) came up with reasonable and more accurate resource expenditure in the management of incomplete abortions. It was found out that for 450 mild cases of incomplete abortion, the cost of treatment was Birr 55,813.50. The highest resource expenditure was for 610 moderate cases, which resulted in Birr 261,332.85 for treatment. As the number of severe cases was few who underwent laparotomy (15 patients), the cost of treatment was only Birr 15,113.55. However, the total cost for the treatment of incomplete abortion incurred by health facilities under this survey was Birr 332,259.90. The average cost therefore, for the treatment of incomplete abortion per woman in government health facilities was estimated at Birr 309.08. This cost estimate showed the direct medical cost incurred without taking into account depreciation costs of facilities, and medical equipment. Other opportunity costs like absence from work, school, and time lost in providing household care, etc. were difficult to either measure or estimate. When the average cost of treatment was disaggregated by severity of illness, it was found out that the direct medical cost showed a progressive increment with the severity of illness. Accordingly, the cost for mild abortion was Birr 124.03, for moderate Birr 428.11, and for severe abortion was Birr 1007.54. This showed that the cost for moderate and severe abortion was more than three-fold and 8-fold, respectively when compared to the mild abortion cases. Table 1: Categories of Severity of unsafe abortion used for the modified Delphi technique Category Procedure Treatment Mild E & C for incomplete abortion without complications E & C, antibiotics, uterotonics Moderate E & C for incomplete abortion with anemia, infection, hemorrhagic/septic shock E & C, antibiotics, uterotonics, IV fluid, blood Severe Laparotomy for perforated uterus,pelvic abscess, and/or generalized peritonitis Laparotomy, antibiotics, uterotonics, IV fluid, blood Table 2: Distribution of women who presented with abortion in selected health institutions in Ethiopia by socio-demographic characteristics Variables Number Percent Age in years <20 173 16.2 20-24 312 29.2 25-29 311 29.1 30-34 154 14.4 35-39 88 8.2 40-45 31 2.9 Occupation House wife 569 53.2 Student 156 14.6 Govt. employee 111 10.4 Unemployed 90 8.4 Others 145 13 Marital status Married 708 66.1 Single 286 26.7 Divorced 28 2.8 Widowed 15 1.4 Separated 4 0.4 Education Illiterate 284 26.5 Read and write 108 10.1 Primary school 182 17 Junior secondary 164 15.3 Secondary school 294 27.5 University/college 38 3.6 Religion Orthodox 514 47.9 Muslim 218 20.4 Protestant 191 17.8 Catholic 66 6.2 Others 82 7.6 Table 3: Distribution of women who presented with incomplete abortion in selected health institutions by their reproductive performance Characteristic Number Percent Gravidity 1 371 34.6 2-4 488 45.6 5-13 213 19.8 Parity 0 371 34.6 1 298 27.8 2-4 289 26.9 5-11 113 10.5 Previous Abortion 0 848 78.8 1 159 14.8 2 41 3.8 3 10 0.9 4 6 0.5 5-12 8 0.7 Previous Induced Abortion 0 993 92.3 1 66 6.1 2 9 0.8 3 5 0.4 4 1 0.1 5 1 0.1 Table 4: Distribution of women who presented with induced abortion in selected health facilities by reasons for terminating pregnancies (n=399)* Reasons Number Percent Need for spacing or not wanting a child 270 67.7 Partner decision 37 9.3 Societies disapproval 37 9.3 Medical reasons 11 2.7 Rape 11 2.7 Others 33 8.3 *A woman can give more than one reason Table 5: Complications identified in women who presented with abortion to selected health facilities. Type of complication Frequency Percent (N=1075) Infection 306 28.4 Endometritis 125 Sepsis 69 Pelvic peritonitis 29 Septic Shock 27 Salpingitis 18 Generalized Peritonitis 9 Pelvic Abscess 7 Tetanus 4 Other 18 Gential Tract Injury 129 12 Cervical Tear 90 Vaginal Laceration 28 Uterine Perforation 8 Other Traumas 3 Foreign Body 17 1.6 Cervix 7 Uterus 7 Vagina 3 Organ Failure 4 Congestive Heart Failure 15 Shock 9 DIC 5 Renal Failure 5 Other 13 Death 13 1,209* Table 6: Comparison of cases with induced and spontaneous abortion by selected Characteristics Categories Induced Spontaneous COR* (95%CI) Abortion Abortion Place of Residence Urban Rural 250 25 619 179 2.8 (1.8-4.6) Days of presentation Non working days 94 216 1.45 (1.06-1.98) Working days 154 513 Knowledge of contraception No Yes 22 253 122 678 2.06(1.2 - 3.5) Rape Yes No 11 202 8 342 2.33 (0.85-6.46) Outcome Dead 8 5 4.7 (1.39-16.79) * COR = Crude Odds Ratio Table 7: Hospital costs of unsafe abortion by category of severity. Category Hospital Stay Procedure Drugs & Supplies Total Mild 2,137.50 33,750 19,926 55,813.50 Moderate 12,361.75 75,000 173,971.10 261,332.85 Severe 712.5 1,350 13,051.05 15,113.55 Total 15,211.75 110,100 206,948.15 332,259.90 Discussion This survey clearly showed the serious problem of unsafe abortion in Ethiopia. The huge unmet need in family planning coupled with poor knowledge and skills of services providers in MVA techniques to avail the necessary services, lack of safe abortion services due to the failure to recognize unsafe abortion as a serious public health problem has led the situation to deteriorate further. Among induced abortion cases the most common reason for termination of pregnancy could be attributed to contraceptive needs. Either the women decided to space or did not want a child at the time of abortion. This may point to certain important facts including the unmet need for contraception and possible use of abortion as a family planning method. In this survey, about two thirds of the respondents tried to terminate pregnancy for contraceptive reasons at the time abortion, as they had decided to space or have no more children. The recent Demographic health survey (DHS) (2) underscored the very low contraceptive prevalence rate (CPR) (6% )for modern methods and 8% for all methods combined, and the unmet need for contraception, which was 40% among married women (2). It is important to note that the proportion of women with induced abortion is higher in women with adequate knowledge of contraceptives. Therefore, looking at the contraceptive knowledge and use profile of the women, one could observe the wide discrepancy in the knowledge and use rate of modern methods of contraception. Most women in this study who resorted to unsafe abortion did not use a method even when the pregnancy was unwanted and unplanned. The fact that 58% of the pregnancy terminations were initiated by the pregnant women themselves or by untrained personnel like friends, relatives or other acquaintances of the woman showed how much desperation or determination there were in the women with unwanted or unplanned pregnancy to get rid of the pregnancy. In addition, the majority of health professionals reported to have conducted the procedure included those who were not formally trained (health assistants, nurses and pharmacists), and are highly likely to lack the necessary skills to safely undertake such procedures. This state of affairs very much increases the procedure related complications. The case fatality rate (CFR) for abortion in this study is very high even by African standard where procedure related deaths are reported to be 600 deaths per 100,000 procedures. The procedure related deaths for developed countries is about 30 deaths per 100,000 procedures (8). Comparison of deaths between spontaneous and induced abortion cases showed that women with induced abortion had more than four times chance of dying from abortion. This is expected, as women with induced abortion are likely to have infection, bleeding, perforation and other complications. Hospital costs for incomplete abortions are very high. Using a combination of primary data generated from this study and secondary data from national figures, it was found out that abortion accounted for 7% (hospital data) of all deliveries. However, the abortion rate can reach as high as 15% of all deliveries. This survey revealed that the mean cost of medical care for abortion treatment is Birr 309, and death secondary to unsafe abortion (the case fatality rate) was 1209 deaths per 100,000 abortions. On the other hand, taking the national crude birth rate at 40 births per 1000 population, and the health service coverage at 50% (2) as secondary data, one could get an estimated 3 million births per annum with an estimated 212,000 abortion cases in the country. Taking the above CFR, there will be an estimated 2,571 deaths from abortion complications alone. This shows the gravity of the abortion situation in the country. Moreover, with the above estimated abortion cases, the total medical cost incurred for the treatment of these cases will be close to Birr 65 million. Taking the health service coverage into consideration, and the availability of existing services, at least 50% of the estimated cost, which is over Birr 32 million, could be incurred by patients or the health service or both. Conclusion Although most respondents 86.6% were aware of family planning methods only 24% had used the services prior to the current abortion. This calls for further study to assess why women are not using contraceptives when they know more about them and yet resort to dangerous abortion procedures. It is of paramount importance to strengthen the national family planning program with effective coordination of the efforts of all stakeholders to enable women have access to quality information, counseling and services in order to minimize unwanted and unplanned pregnancy and the resort to unsafe abortion. Over 45% o all abortions occurred in adolescents and the younger age group that are more likely to have irregular, unplanned, hurried and clandestine sexual behavior. Under such circumstances, use of emergency contraception can prevent a lot of unwanted pregnancies and hence reduce unsafe abortion. Therefore, introduction and promotion of EC in the country would greatly reduce the rate of unwanted pregnancy and thereby decrease the high maternal deaths associated with unsafe abortion. Majority of service providers (81%) resorted to sharp metallic curettage as opposed to MVA (11%), which is currently considered a safe method. Furthermore, mid-level health workers initiated 27.8% of all abortions, which is an important role in abortion care provision. Although this activity is not formally recognized by the public sector, there is an urgent need to recognize this role, and organize trainings on post abortion care (PAC) at all levels. Therefore, there is a need for initiating and strengthening a national training and services program on PAC. Contraceptive method failure was responsible for 18% of all pregnancies that resulted in unsafe abortion, and was the second commonest reason for occurrence of unwanted and unplanned pregnancies. Rape also contributed 3% of abortion cases. Until safe abortion services are available on demand, it is a high time that those women who become pregnant subsequent to method failure and rape be provided with safe abortion services. Unsafe abortion should get the necessary recognition as a major public health problem in the country. This recognition is expected to lead for the liberalization of the abortion law in the country. In this regard, conducting an advocacy work among policy makers by utilizing information generated from this study and from within the country would help to bring about a change in the abortion law. The above cost projections that were calculated clearly demonstrate the fact that abortion is not only a public health problem of national significance in terms of morbidity and mortality, but it has also got an economical dimension, which should not be underestimated. It is necessary therefore to conduct the necessary advocacy work at federal and regional levels particularly on the cost issue. It is understood that the available meager resources of the country should not be consumed for the treatment of abortion. Acknowledgements We express our gratitude and appreciation to UNFPA for its financial assistance to undertake this survey. Our special thanks go to Dr. Benson Morah, UNFPA Country Representative, and Program Officers Ato Abate Gudunfa and Miss Nina Storm. We also acknowledge the Regional Health Bureaus and Medical Directors of health facilities whose participation and support made possible the successful completion of this study. Finally, our special thanks go to patients who volunteered to be included in the study and members of ESOG for their help at various stages of the study. References 1. Ministry of Health/World Health Organization (MOH/WHO). 2003. Reduce Model: An advocacy tool for accelerated reduction of maternal and newborn morbidity and mortality in Ethiopia. Addis Ababa, Ethiopia. 2. United Nations. Report of International Conference on Population and Development. Cairo, 5-13 September 1994. Report A/CONF. 171/13. New York. 3. Kwast BE, Rochal RW, Widad Kidane Mariam. Maternal mortality in Addis Ababa, Ethiopia. Studies in Family Planning, 1986, 17(6):288-301. 4. Yoseph S. and Kifle G. A six –year review of maternal mortality in a teaching hospital in Addis Ababa. Ethiop. Med. J. 1988;26:115-20. 5. Yoseph S, Gossa A. Tadesse E, et al. A survey of illegal abortion in Addis Ababa (Unpublished report) 1993. 6. Federal Democratic Republic of Ethiopia, Ministry of Health. Health and health related indicators. January 1998, page 32. Addis Ababa, Ethiopia. 7. Central Statistical Authority (CSA) and ORC Macro. 2001. Ethiopia Demographic & Health Survey. Addis Ababa, Ethiopia: CSA & ORC Macro. 8. Winkler, Judith, Elizabeth Oliveras and Noel McIntosh,eds. Post abortion Care: A reference manual for improving quality of care, 1995,USA, Post Abortion Care Consortium.

Introduction Worldwide, there are 30 - 50 million induced abortions that result in the death of 80,000 - 110,000 women of which an estimated 34,000 are in Sub - Saharan Africa (1). One of the causes of death is uterine perforation, which is particularly dangerous if the abortion is unsafe or is not recognized in time. The incidence is estimated to be 0.2 - 15/1,000 abortions. Depending on the setting, instruments used to terminate pregnancy can be plastic material, plant roots, metallic rods or sharps, or surgical instruments like dilators and curettes (2,3,4). Reports from different settings have identified risk factors, sites of perforation, clinical presentations, method of diagnosis and outcome. In one study most perforations (64%) occurred in the corpus and the remaining 36% in the cervico-isthmic region (2, 5). Associated complications also vary depending on the circumstances of the procedure. In reports where abortion is legally procured the complications mainly are bleeding and trauma to other visceral organs (5). On the other hand, unsafe abortion is commonly associated with sepsis, anemia, and hypovolemic shock (3, 4). Recommended management options for such case are repair, evacuation and curettage under direct visualization followed by repair, total abdominal hysterectomy with or without oophorectomy, subtotal hysterectomy, repair of bowel, or colostomy with subsequent closure. If the abortion is safely procured vigilant observation and oral antibiotic therapy can be all one should do (7, 8, 9). Like in other areas where abortion is unsafely procured, we encounter cases of uterine perforation in our practice. Specific study with regard to uterine perforation, however, is not reported in the Ethiopian setting. Thus, this study was carried out to determine the incidence, clinical presentation, site of perforation, mode of management, associated complications, and outcome of women with uterine perforation in a teaching hospital. This study will provide a baseline data and help in generating hypothesis for future large-scale studies. Materials and Methods This is a case series of uterine perforation in two years between September 11, 1999 and September 10, 2001 in a tertiary university hospital, Addis Ababa, Ethiopia. The study subjects are all cases of uterine perforation who presented to the study hospital during the specified period, and the diagnosis is confirmed at laparatomy. Uterine perforations that are not due to abortion, suspected cases that responded to conservative management, charts with incomplete information and cases whose charts could not be retrieved are excluded from the study. But, in the later two conditions the number is considered to estimate the prevalence. Total number of abortions was obtained from the abortion registry logbook both in the wards and the out patient department. The number of cases of uterine perforation is obtained from the major operation registry. Charts of the cases was obtained from the hospital registrar after proper procedures and the following information was collected; sociodemographic data, reproductive history, conditions around the termination of the pregnancy, clinical presentation, operative findings, site of perforation, mode of management, presence of complications and outcome of treatment. The relevant information was obtained from each patient’s clinical record. Data was collected and computed manually. Simple percentage is used for description of frequency of data. Information in the patients’ charts was kept confidential. Results There were a total of 927 abortions during the two years of the study of which 25 had laparatomy proven uterine perforation. This makes the prevalence 27/1000 abortions. Two third, 16/25, of the cases were young women under 25 years old. Socio demographic data is shown on Table 1. Table 1. Sociodemographic characteristics of cases of uterine perforation in a university teaching hospital, Addis Ababa, Ethiopia. September 1999-2001. Age Number % 15 – 19 5 20 20 – 24 11 44 25 – 29 7 28 30 – 35 2 8 Parity Nullipara 13 52 I-IV 11 44 Unknown 1 4 Marital Status Single 18 72 Married 4 16 Divorced 2 8 Unknown 1 4 Occupation Unemployed 5 20 Student 5 20 House wife 3 12 Housemaid 3 12 Others * 5 20 Unknown 4 16 *This includes merchants, commercial sex workers, private workers One in five cases denied any attempt to terminate the pregnancy. Termination was performed in private health institutions, backstreet and at home in seven, six and two cases, respectively. Place of interference is unknown in the remaining 10. Plastic materials were used for interference in eight, metals in five and plant root and wooden material in one each. In 36% (9/25) termination was attempted after 14 weeks of gestation. Seven cases came within three days of interference, 10 came between the third and seventh day and the rest eight came after a week has passed. Abdominal pain, abnormal vital signs, pallor and signs of peritonitis were found to be consistent symptoms and signs in cases with uterine perforation. Clinical information is shown in Table 2. Table 2. Clinical presentation of 25 cases of uterine perforation in university teaching hospital, Addis Ababa, Ethiopia. September 1999-2001. Clinical Signs/symptoms Frequency * % Abdominal pain 25 100 Signs of peritonitis 25 100 Pallor 24 96 Vaginal bleeding 19 76 Fever 19 76 Adnexal mass 14 56 Chills/rigors 9 36 Offensive vaginal discharge 8 32 Vomiting 7 28 Abdominal distention 5 20 Diarrhea 4 16 Others * 12 64 * Rounding up is far from 100% because multiple complaints is the rule than the exception ** These include poor appetite, passing air and feces through vagina, visible loops of bowel through vagina, jaundice, traumatized birth canal and change of sensorium. Only one patient had a hematocrit in the normal range, four women had hematocrit less than 20%. WBC was less than 10,000 in one third. Culdocentesis was done in eight cases of which five revealed non clotting blood and three purulent fluids. Uterine sounding was diagnostic in six of the nine in whom it was attempted. In the remaining three the defect was not identified preoperatively. Ultrasound showed fluid only in two out of seven. Intraoperatively, nine of the 24 women had a uterine size of greater than 12 weeks. Two had a normal sized uterus. Bowel injury was described in six of the 25; one at the ileocecal junction, one on the rectum and four on the ileum. Documented operative findings are shown on Table 3. Table 3. Operative findings in 25 cases of uterine perforation in university teaching hospital, Addis Ababa, Ethiopia. September 1999-2001. Finding Number % Abscess 16 64 Inflamed ovary 14 56 Inflamed tubes 13 52 Adhesion 11 44 Blood in abdominal cavity 10 40 Bowel injury 6 24 The site of perforation was the posterior and anterior aspect of the corpus in 11 (44%) and 4 (16%), cervico-isthmic 7 (28%), lateral in 2 (8%) and cornual in one case. The duration of operation was more than 60 minutes in 21 (84%) and more than 120 minutes in 9 (32%). Mode of management is described on Table 4. Of the total 25 cases seven were admitted to surgical ICU for respiratory support. Surgical consultation for bowel injury and medical consultation for adult respiratory distress syndrome was made for five and three cases, respectively. Table 4. Mode of management of the 25 cases of uterine perforation in university teaching hospital, Addis Ababa, Ethiopia. September 1999-2001. Operative management Number % Drainage and lavage 21 84 Hysterectomy * 19 76 Adnexectomy ** 15 60 Adhesiolysis 11 44 Repai of uterine defect 5 20 Uterine curettage 5 20 Resection and end to end Anastomosis 4 16 Colostomy and repair of rectum 1 4 *Subtotal hysterectomy was performed in four cases **Unilateral adnexectomy was performed in three cases ^bruise on ileocecal junction was left alone Table 5 shows complications that developed in patients with uterine perforation. Hospital stay ranged from one to 45 days; the mode was six and the median 10. There were eight maternal deaths making the case fatality rate of uterine perforation presenting to our hospital 32%. Only six women returned for follow up. Table 5. Associated complications in 25 cases of uterine perforation in university teaching hospital, Addis Ababa, Ethiopia. September 1999-2001. Complications Frequency % Peritonitis 25 100 Sepsis 25 100 Anemia 24 96 ARDS 8 32 Wound infection 8 32 Septic shock 6 24 16Renal failure 4 16 W12ound dehiscence 3 12 DIC12 3 12 Hypoc8alcaemia 2 8 Relapar4atomy 1 4 Discussion A number of complications are described following induced abortion. One serious complication is uterine perforation that occurs in 0.2 - 15 cases per 1000 induced abortions depending on the population studied (5, 10). The rate in our hospital, 27/1000, is far more common than the reported range. Several studies from different corners of the world have identified risk factors that operate individually or in combination. These risk factors include position of the uterus during procedure, gestational age, skill of the provider, higher order parity, the place where it is procured, and the instruments used to induce the abortion (5, 7, 10). The perforating instruments are mostly unknown, but depending on the setting it may vary from medical instruments to twigs of plants, plastic and metallic materials. For example, one study done in five hospitals in Addis Ababa showed that metallic rods, plastic materials and plant roots are the common substances used to induce abortion (2). Another study from Kenya indicated that instruments used to interfere with the pregnancy included knitting needles, ball-point pens, hangars, and iron rods (3). Similarly, we have found that plastic materials and metallic instruments were responsible for causing uterine perforation in 8/25 and 5/25 cases, respectively. On the other hand, the perforating instruments in the report from US America were dilators in 34%, suction cannulae in 28%, sharp curettes in 25% and uterine sound in 13% (2). Sites of perforation are also different in different studies. It can be on the anterior or posterior wall, cornual, fundal or cervical portion, or cervico isthmic or broad ligament area (5, 7, 10). In one study the site of perforation reported from 47 patients lateral was in 40%, right lateral in 21%, left lateral was in 17%, posterior in 13% and fundal in 9%. In the same study, most perforations (64%) occurred in the corpus while the remaining 36% occurred in the cervico isthmic region. Another study reported that 16 of 20 (80%) perforations were located in the cervix or lower uterine segment (8). Both studies are conducted where abortion is procured safely in health institutions. In our study where abortion is unsafe the site of perforation was mostly anterior corpus and cervico-isthmic in 11 and 7 of the total 25 cases, respectively. Associated complications like sepsis, hemorrhage, gut injury, and vesicovaginal fistula are reported (6,7 ,8,10). Bowel injury was reported in three and uncontrollable hemorrhage in six of the total 28 cases following elective termination of pregnancy (7). In another study, bowel injury occurred in two, fever in 10 and hemorrhage severe enough to require blood transfusion in 17 of 66 women who sustained confirmed uterine perforation (8). The complications identified in this study are not different from those described above. In agreement with the general recommended management options (6, 9) total abdominal hysterectomy with or without oophorectomy, evacuation and curettage under direct visualization followed by repair, subtotal hysterectomy, repair of bowl, and colostomy with subsequent closure was performed in 15, 5, 4, 4, and one case, respectively. Vigilant observation and oral antibiotic therapy can also be one mode of management if the abortion is safe. Freiman (4) et al managed 12 of 28 (43%) cases as such. The final outcome is different and includes chronic pelvic pain, ectopic pregnancy, infertility, or a maternal mortality. Reports from different areas show that mortality from abortion varies from 1.1 - 6% (2, -4, 10). But, this report show that 8 of 25 (32%) cases of uterine perforations died implying death rate in such cases can increase five to 30 fold. Because of poor follow up rate long term complications could not be described. In conclusion, uterine perforation is associated with increasing number of complications including death. Physicians catering to health care of women with unsafe abortion shall exhibit a high index of suspicion for uterine perforation. References 1. WHO. Complications of abortion. Technical and managerial guidelines. WHO, Geneva, Switzerland 1994. 2. Yoseph S, Gossa A, Tadesse E, Mulleta I, et al. A survey of illegal abortion in Addis Ababa, Ethiopia. 1993 (Unpublished report) 3. Agarwal VP, Mati JKG. Epidemiology of induced abortion in Nairobi, Kenya. J obstet Gynecol East Cent Africa 1982; 1:54 - 57. 4. Madebo T, G/Tsadik T. A six month prospective study on different aspects of abortion. Ethiop. Med J 1993; 31: 165-72. 5. Grimes DA, Schulz KF, Cates WJ. Prevention of uterine perforation during curettage abortion. JAMA 1984; 251 (16):2108 - 2111. 6. Grimes DA, Cates W. Complications from legally-induced abortion: A review. Obstet Gynecol Surv 1979; 34: 177 - 189. 7. Freiman SM, Wulff JL. Management of uterine perforation following elective abortion. Obstet Gynecol 1977; 50: 647 - 650. 8. Berek JS, Stubblefield PG. Anatomic and clinical correlates of uterine perforation. Am J Obstet Gynecol 1979; 135: 181 - 185. 9. Stubblefield PG. Termination of pregnancy. In: Normal and problem pregnancy. Ed Gabbe S. Charstone, New York, New York. 1996; pp 371 - 397. 10. Obeds WJ. Uterine perforation from induced abortion. West Afr J Med 1999; 18; 286 - 289.

Introduction Hypertensive disorders of pregnancy are common and form one of the deadly triads of maternal mortality. In a report from the USA by Berg and colleagues (1996), 18% of maternal deaths from 1987-1990 were related to pregnancy induced hypertension. Reports from developing countries indicate that PIH particularly eclampsia account for about 11% of maternal mortality being only third to hemorrhage, 24% and infectious causes 17% (1,2). Of all the diverse conditions lumped under the broad classification of PIH, eclampsia poses the greatest risk to maternal mortality. Eclampsia is the occurrence of convulsions and/or coma unrelated to other cerebral conditions in a patient with signs and symptoms of preeclampsia. Eclampsia is primarily a disease of the young primigravida. Stroganoff in 1900 reported 5.4% mortality compared to 17-29% for European clinics and 21-49% for American clinics of the same period (3). Current incidence in the developed world is small and varies from 0.27 per thousand to 0.49 per thousand 4-8 The rate in developing countries is as high as 13 per thousand deliveries. The provision of ANC services, early diagnosis and hospitalization with administration of prophylactic magnesium sulphate for severe pre eclampsia is said to contribute to the markedly lower incidence in the developed world (9). The few available data from Ethiopia report incidences of 3.1-3.3 per thousand deliveries in 1989 and 1969 respectively (10, 11). A 7.1 per thousand incidence was noted at two teaching hospitals in Addis Ababa in a five year period by Abate in 1999 12. He noted that the incidence of eclampsia was higher in those without ANC and twin gestations. Eclamptic convulsions may occur antepartum (50%), intrapartum or postpartum (25% each) (13). Severe preeclampsia and eclampsia present management challenges which may only be successfully met by facilities and expertise offered in high dependency or intensive care units (HDU/ ICU). Both are characterized by the availability of more intensive nursing and medical care and more sophisticated monitoring and support of vital functions that is not available in general wards. Eclamptics require intensive care when there is failure of the function of an organ system/s. A dedicated obstetric HDU/ICU is highly desirable in the early detection and management of eclampsia complications. Any woman in whom the diagnosis of severe preeclampsia or eclampsia is made is ideally managed in a HDU. The common indications for transfer to an ICU are refractory eclampsia, respiratory failure, cardiovascular instability, central monitoring and renal insufficiency (14). The primary goal of treatment of women with eclampsia is to control the BP, control convulsions and termination of pregnancy (15). When eclampsia is complicated with end organ damage, additional management in reference to organ support until the acute episode subsides is required. There is a severe shortage of facilities for intensive care in low-resource countries like Ethiopia. This creates difficulties in timely transfer of eclamptics for intensive care and at times death prior to transfer. The aim of this study is to identify possible risk factors associated with mortality from complications of eclampsia. This will give insight as to which groups of patients would benefit from early referral, transfer or admission for management in the SICU in order to improve survival in the face of the scarce resources and manpower in our setting. TAH-SICU is the only facility in Addis Ababa where eclamptic patients referred from the city requiring intensive care are admitted and managed. It is reasonable to consider that data obtained from patients admitted to this unit may give insight as to the main clinical data of the eclamptic episode, the obstetric profile, therapeutic measures taken and the risk factors associated and frequency of complications among those that survived and those who died in the Ethiopian setting. The objective of the study is to evaluate risk factors associated with mortality in eclamptic patients who required intensive care after admission to Tikur Anbessa Hospital SICU during the study period. Subjects and Methods A ten year hospital based retrospective case-control study on eclamptics admitted to the surgical intensive care unit of Tikur Anbessa Hospital- a central referral hospital -covering the period from October 1995 to September 2004 was conducted. All eclamptics admitted and managed at the unit during the study period were included in the study. Those who died at the SICU were taken as cases, while those who were discharged or transferred improved were the controls. Tikur Anbessa Hospital is a central referral hospital in Addis Ababa, Ethiopia equipped with a SICU staffed by anesthesiologists, anesthesia residents and trained nurses. The ICU has six beds and as the only ICU in the city at the time of the study, all eclamptics who required intensive care during the studied period were admitted to the unit. Due to the shortage of ICU beds only patients who fulfill certain criteria are granted admission to the ICU. These include unstable vital signs, airway obstruction, respiratory failure and immediate postoperative cases. Admitted cases of eclampsia were identified from the SICU admission and discharge registration book, their case records retrieved from the hospital archives and information on sociodemographic and clinical parameters were collected using a structured data collection format. The EPI-Info Version 6 statistical software was used to analyze the data. The chi-square test was used to compare proportions and a p-value of 0.05 was taken as the significance level. Odd’s ratios with 95% CI were computed for comparison variables. Multivariate analysis of age and parity was done using the SPSS statistical software. Results During the ten years studied, 176 eclamptics were admitted to the SICU of the hospital. From the archives, 147 (83.5%) charts were retrieved. Admission rates for eclampsia progressively increased from 3(2%) in 1995 to 22(15%) in 2004 of total SICU admissions. Majorities were in the age groups of 20-29, 83 (56.5%), (Table 1, 2). Patients age ranged from 15-39 years with the mean age of all eclamptics being 23.4 (SD 5.2). Survivors had a significantly less age 22.6 (SD 4.9) compared to those who died 25.6(SD 5.6) (P<0.01). Age greater than 29 was significantly associated with risk of dying (OR 3.29; 95% CI 1.18-9.12). Six (15.8%) were housemaids among those who died compared with 3(2.8%) of the survivors. Being a housemaid (OR 6.63, 95%CI 1.36-35.15) and multiparity (OR 5.93, 95% CI 1.13-34.00) were significantly associated with a higher risk of death. Multivariate analysis showed that both age greater than 30 years (OR 4.15, 95% CI 1.11-15.5) and multiparity (OR 2.55, 95% CI 1.05-6.02) were independent risk factors for dying. Table 1- Sociodemographic characteristics of eclamptic admissions to the SICU, Tikur Anbessa Hospital, Addis Ababa, Ethiopia, 1995-2004. Table 2- Possible risk factors associated with maternal mortality among eclamptics admitted to the SICU of Tikur Anbessa Hospital, Addis Ababa, Ethiopia, 1995-2004. Table 3 indicates the main obstetric profile and other clinical parameters of patients. Twin delivery rate was 18(12.2%) of the total. 45(30.6%) of the patients had no antenatal care. No significant association was detected between antenatal attendance and twin delivery with a higher risk of death. Premonitory symptoms were documented in 95(64.6%) of the total with 34(35.8%) having at least one; 41(43.1%) had two or three symptoms while 20(21.1%) had none. Onset of convulsions were antepartum in 102(69.4%), intrapartum in 23(15.6%) and postpartum in 22(15.0%). The maximum mean systolic and diastolic blood pressures of the total cases were 175.4 mmHg and 118.8mmHg respectively. The maximum mean systolic blood pressures among those who died and survived were 181.7mmHg and 173.0 mmHg respectively. The maximum mean diastolic blood pressures among those who died and survived were 119.7 and 118.4 mmHg, respectively. There was no statistically significant difference in the maximum mean systolic and diastolic blood pressures of the cases and controls. Lateralizing signs were present in 11(7.5%) of the patients at hospital admission; 6(18.8%) of those who died compared to 5(4.8%) of survivors. Presence of lateralizing signs was significantly associated with a risk of dying (OR 4.57; 95% CI 1.12-19.04). Immediate reasons for transfer to SICU included respiratory complications 64 (43.5%); neurologic complications 53 (36.1%); uncontrolled convulsions 32 (21.8%); acute renal failure 23 (15.6%); providers conviction for need to critical care 26 (17.7%) and uncontrolled hypertension in 18(12.2%). Respiratory complications included aspiration, hospital acquired pneumonia, respiratory failure, pulmonary oedema and adult respiratory distress syndrome. Neurologic complications encountered were prolonged coma, blindness, brain death and possible intracranial hemorrhage. The presence of neurological complications (OR 4.04; 95% CI 1.74-9.45) and respiratory complications (OR 2.54; 95% CI 1.12-5.82) were significantly associated with risk of dying compared to other admission diagnosis. Twenty six (19.8%) of total patients had oliguria; 15 (46.9%) of them died compared to 11(12.1%) who survivors. Presence of oliguria was significantly associated with mortality risk (OR 6.4; 95% CI 2.33-17.86). Main interventions undertaken at the SICU included mechanical ventilation for 90(61.2%); central venous pressure monitoring for 36(24.5%) and dialysis for 2. One hundred and nine (74.1%) of the total patients admitted were transferred to the wards improved while 38(25.9%) died at the SICU (case-fatality rate). Thirteen (34.2%) of the deaths were admitted in a moribund state with evidences of brain death making the corrected case fatality rate in SICU 25 (18.7%). The mean duration of stay in the SICU was four days and nineteen hours. The commonest causes of death were multiple organ failure 24(63.2%), neurologic complications in 18(47.4%) and respiratory failure in 12(31.6%). Other causes included shock in 9(23.7%), acute renal failure 8 (21.1%), cardiopulmonary arrest 8(21.1%) and anesthesia complications in 4(10.5%). Table 3- Main obstetric profile and clinical data of eclamptics admitted to the SICU at Tikur Anbessa Hospital, Addis Ababa, Ethiopia, 1995-2004. Discussion Utilization of SICU services for eclamptics progressively increased over the years indicating increased awareness of health professionals of the comparative advantages in outcome. The higher risk of death noted in women older than 30 years of age and the multipara, is possibly due to delayed health seeking behavior due to possibly uneventful previous birth experiences or decrement in physiologic reserves as age advances. Older age and multiparity were independently associated with the risk of dying agreeing with other authors that while primigravidity may be the most important risk for the development of preeclampsia, multiparity is the risk associated with higher maternal mortality. Low socio economic groups such as housemaids had higher mortality most likely due to being uneducated, underprivileged, likely to have unwanted pregnancy and being late to seek medical attention. A significant number 30.6% had no antenatal care contributing to late presentation and a high case fatality rate. Presence of lateralizing signs and neurologic involvement such as deep prolonged coma was associated with poor outcome indicating that the prognosis of patients with cerebral involvement is poor. Lack of computerized tomography or magnetic resonance imaging studies to identify the specific cause of coma and neurologic complications and institute appropriate therapy may be responsible for the poor outcome. This deficiency is noted to be a serious limitation to critical care of eclamptics at the hospital. Several limitations in quality of critical care provision were noted. Important laboratory investigations were not recorded and possibly not determined including urinary protein in 18.4%, hematocrit in 4.7%, blood group in 14.3%, platelet count in 46.9% and renal/liver function tests in 34%. This may be due failure to consider performing these tests, poor recording but most likely are because of failure of the patient to afford the costs or inadequate supply of reagents by the hospital. Only 24.5% of the patients had CVP monitoring and only two out of eight women who required dialysis actually obtained the service indicating that a significant proportion of the women may not have received the necessary critical care they required due to lack of facilities and manpower. This fact per se may have contributed to mortality risk. The unavailability of magnesium sulphate for convulsion control may also contribute to poor outcome due to its documented superiority over diazepam in the management of eclampsia. This is one aspect of the management requiring urgent attention. Both the gross and corrected case fatality rates are markedly high. Being the only referral hospital for SICU care, this may not be surprising since critical and complicated patients are referred from other hospitals. Scarce resources and manpower, delay in are referral and suboptimal SICU care are potentially responsible for this very high figure. Early referral for SICU care of older women, the multipara, those with pulmonary and neurologic complications and those of low socioeconomic group may improve survival. The study has also shown that the quality of SICU care is often lacking in essential facilities which need to be addressed. Establishment of a dedicated obstetric high dependency unit (HDU) or ICU is highly desirable for early detection and management of complications of eclampsia. Although all mothers with eclampsia deserve ICU care, provision of such services will be impossible in the near future in low-resource settings in Africa. Till that is possible, using selective criteria such as mothers with the above mentioned risk factors for admission to SICU may be one approach for effectively utilizing the limited resources. As this study is retrospective and of small sample size, conducting a larger study to better clarify risk factors for mortality following eclampsia requiring ICU care is recommended. Such a study will help in outlining indicators useful in identifying eclamptics who would benefit from early referral for intensive care. Reference: Cunningham F.G. et al. William’s Obstetrics, 21st Edition, 1997, 567-618. Health, Infectious Diseases and Nutrition, U.S. Agency for International Development, Bureau for Global Health, 2003. Gabbe S.G. et al. Normal and Problem Pregnancies, Fourth Edition, 2002, 945-983. ACOG Practice Bulletin, Diagnosis and Management of Preeclampsia and Eclampsia. Int. J.Gynecol.Obstet., 2002, 77, 33:67-75. Moller B.S., Lindmark G. Eclampsia in Sweden. Acta Obstet Gynecol Scan, 1993; 9-14. Douglas K.A., Redman C.W.G. Eclampsia in the United Kingdom. BMJ, 1994, 309: 1395-1399. Pritchard J.A., Cunningham F.G., Pritchard S.A. The Parkland Memorial Hospital Protocol for treatment of eclampsia: Evaluation of 245 cases. Am. J. Obstet, Gynecol., 1990, 148: 951-963. Eclampsia Trial Collaborative Group: Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet, 1994; 345:1455-1463. Robson S.C., Magnesium Sulphate: The time of reacting to obstetrics and gynecology. BMJ, 1996, 103:99:1-2. Jackson A.P.F. Eclampsia in Addis Ababa. Ethiop. Med. J., 1970; 8; 123-128. Mekbib T., Ketsela K. Preeclampsia/Eclampsia at Yekatit 12 Hospital, Addis Ababa, Ethiopia. East African Med. J., 1991, 68,893. Abate M. Eclampsia: A retrospective review in two teaching hospitals in Addis Ababa, 1999. (Unpublished thesis). Dekker G.A. Risk factors for preeclampsia. Clinical Obstet Gynecol., 1999, 42, 3:422-435. Mario-Lopez M. Complicated eclampsia. Am. J. Obstet. Gynecol., 1992, 168:4-91. Management protocol for PIH, Addis Ababa University, Department of Obstetrics and Gynecology. 2002, 48-56.

GLOBAL MEDICAL ETHICS: 1 Division of Medical Ethics, Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway 2 Centre for International Health, University of Bergen, Bergen, Norway 3 Arba Minch Hospital, Arba Minch, Ethiopia Correspondence to: Kjell Arne Johansson, Division of Medical Ethics, Department of Public Health and Primary Health Care, Centre for International Health, University of Bergen, PB 7804, 5020 Bergen, Norway; Kjell.Johansson@isf.uib.no

HISTORY AND CURRENT STATUS: A cursory look at the history of the use of traditional medicine (especially of medicinal plants) in Ethiopia reveals that such use dates back to the time of the Axumite kingdom, if not to earlier periods. Many manuscripts attesting to this fact, and which are now in the custody of the Ethiopian National Traditional Medicine Preparation and Therapy Association, have been recovered. They mention, among other traditional practices, that a large number of medicinal plants were used. The manuscripts claim that during the era of the Axumite kingdom (7th-11th C), about 8,000 plants were used as medicinal agents. This period was followed by the Zagwe dynasty (11th-13th C), during which time about 2,800 medicinal plants were recorded to have been used. Similarly, during the era of Gondarine kingdom (1636-1865), medicinal plants numbering some 2,900 were employed. A manuscript was also recovered from the ruins of Aba Jifar's palace in Jimma during the era of King Menelik II over 100 years ago. It included about 589 plants which were used as therapeutic agents. Close to 700 medicinal plants were also recorded to have been used during the reigns of King Hailemelekot through Emperor Haile Selassie I (1870-1974). In each of the above manuscripts, a lesser number of other medicinal agents of animal and mineral origins were also presented. It is worth noting that the number of plants may have been exaggerated, especially in the older manuscripts, considering the fact that only about 7,500 plant species are known to exist in Ethiopia today. It is also possible that many of the plants may have been counted more than once. This may be true even after allowing for plant species that could have been extinct since the times of the manuscripts. In any event, it is clear that medicinal plants played a pivotal role in the treatment of various afflictions. More recently, several publications which listed currently used Ethiopian medicinal plants have appeared. In 1971, Tsehai Berhane Selassie authored an annotated paper based on an earlier manuscript by Grazmach Gebrewold Aregawi of Dega Damot, which described the uses of over 200 plants. In addition, the paper included a description of magic and rituals used in some of the healing processes. In 1973, the Polish Stephen Strelcyn produced a book listing the medical applications of 300 plants. A few years later, in 1976 a mimeograph was published by the University of Addis Ababa, based on extensive field and herbarium studies. This work listed the geographic origins of about 250 medicinal plants along with their uses. A landmark book titled Este Debdabe was published in 1989 by Gelahun Abate, with Sebsebe Demissew as the editor. This publication in turn included descriptions of over 250 medicinal herbs. Most recently, a comprehensive book authored by Dawit Abate and Ahadu Ayehu came out in 1993. The book elaborated the uses of about 240 medicinal plants. Since 2001, a few critical books dealing with various aspects of Ethiopian medicinal plants have been published. Presently, there are anywhere between 650 and 1,000 medicinal plants in Ethiopia, comprising about 10 per cent of the entire flowering plants found in the country. However, perhaps the more commonly used medicinal plants may number in the vicinity of 200. Many of these plants have not been investigated scientifically, although they have been used by the population for a long time. A common argument advanced in favor of continuity of use of such long-used plants is that people would have dropped them if they hadn't worked, and therefore they should have been effective to be sustained for such a long time. However, that reasoning doesn't suffice to promote rational use of phytomedicines. Scientific studies encompassing chemistry, pharmacology, formulation and standardization are required not only to justify the use of botanicals (when there are cases to justify), but also to produce refined, convenient, and quality-controlled products. It has been widely claimed that about 80% of Ethiopians rely on traditional medicine (predominantly medicinal plants) to treat their illnesses and maintain their health. This is more true in rural than urban areas. Even in urban areas people are inclined to use so-called home remedies to treat common illness symptoms. In such cases, accurate diagnoses of diseases, and expertise in preparing and administering herbal medications may not be usually required. In this category of conditions fall such disease states as taeniasis, stomach conditions, skin problems, and symptoms such as headache, cold, cough, and diarrhea. People have treated these conditions for hundreds (maybe even thousands) of years by using traditional ways. They have been successful in most cases in alleviating their suffering by concocting various preparations derived from medicinal herbs which abounded in their environs. More serious medical problems were usually deferred to "expert" traditional medical practitioners, or modern physicians as the case may be. Ethiopian traditional medicine consists of various treatment modalities, but the bulk of it employs medicinal plants as part of the treatment regimens. Consistent with the prevailing thoughts of the time, many of the old treatment methods were, as can be expected, steeped in magico-religious beliefs. As time went by, traditional medicine started receiving fresh perspectives. A number of medicinal plants have survived scientific scrutiny to varying degrees.

FUTURE PROPESCTS: It is obvious that Ethiopian medicinal plants are a rich source of many remedies. In a country where modern health services are out of reach for about 80% of the population, these plants provide an alternative ammunition to fight a number of diseases. Even with the future expansion of modern health services to cover the underserved section of the population, it is quite conceivable that, if properly harnessed, botanical remedies can provide a complementary source to modern medication supply. In order to ensure their sustainability, Ethiopian medicinal plants need to be conserved, lest they be endangered and eventually be extinct as a result of unbridled deforestation and natural calamities. A sound conservation program aimed at preserving this rich biota is a pre-requisite. Along with such a program, the foundation of a light modern botanical products industry needs to be laid down. Policy makers need to provide legislative and infra-structural support to entrepreneurs who may wish to invest in businesses to develop medicinal plant products.

KEY REFRENCES: Berhane Selassie, T. (1971). An Ethiopian Medical Text-Book, Written by Gerazmach Gebrawld Aragahn, Daga Damot. Journal of Ethiopian Studies IX (1): 95-180. Strelcyn, S. (1973). Medicines et. Plantes D'Ethiopie. Instituto Universitario Orientale, Napoli. Abate, G. [edited by Demissew, S] (1989). Etse Debdabe (Ethiopian Traditional Medicine). Biology Department, Addis Ababa University. Abebe, D. and Ayehu, A. (1993). Medicinal Plants and Enigmatic Health Practices of Northern Ethiopia. B.S.P.E., Addis Ababa. Zewdu, M. and Demissie, A. (2001). Conservation and Sustainable Use of Medicinal Plants in Ethiopia. Institute of Biodiversity Conservation and Research, Addis Ababa. Fullas, F. (2001). Ethiopian Traditional Medicine: Common Medicinal Plants in Perspective. Sioux City, IA (USA). Fullas, F. (2003). Spice Plants in Ethiopia: Their Culinary and Medicinal Applications, Sioux City, IA (USA).

RESULT: In this study many journals and written articles has been surveyed to assess about onchocerciasis in Ethiopia. A total of 12445 study subjects from 21 articles were selected and included in the study. Table 1 summarizes the distribution of studies in different areas of the country listing study area, sample size, Age ranges and prevalence in chronological order.