Abortion, when performed under widely accepted clinical guidelines, is considered a safe medical procedure, according to specialists in the field.
But a secret abortion program led by the Nigerian Army in the country’s northeast, revealed in a Reuters investigation published Wednesday, departed significantly from what experts consider accepted medical practice.
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Since at least 2013, the Nigerian Army has run a secret, systematic and illegal abortion program in the country’s northeast, terminating at least 10,000 pregnancies among women and girls, many of whom had been kidnapped and raped by Islamist militants, according to dozens of witness accounts and documentation reviewed by Reuters.
Nigerian military authorities deny the program has ever existed. Abortion is illegal in Nigeria except to save the life of the mother.
Women given abortions in the Nigerian program were in the custody of armed soldiers. Reuters found that some did not even know they were pregnant, and some were deceived or physically forced into abortions that sometimes resulted in injury or death. Abortions are considered to be forced when they are performed without the prior, informed and free consent of the women, according to the European Institute for Gender Equality and the U.N. Committee on the Elimination of Discrimination against Women.
Reuters briefed five doctors who specialize in abortion about its findings on the medical practices employed in the program. None was directly familiar with the program or able to comment specifically on it. But they agreed to assess the potential risks to patients that would be posed by the practices described by Reuters.
Reporters also reviewed guidelines on abortions issued by the World Health Organization (WHO) and the United Kingdom’s National Institute for Health and Care Excellence, among other authorities.
Among the potential risks and concerns raised:
* The women often were in a debilitated condition – malnourished, injured or otherwise unhealthy before being taken into military custody.
In such cases, they could be vulnerable to anemia, vitamin deficiency and other afflictions that make it harder for the body to cope with bleeding or any complications during an abortion.
For the malnourished, low hemoglobin levels mean “it doesn’t take much blood loss to have severe harm,” said Andrew Weeks, a British consultant obstetrician who specializes in maternal health and has worked in East Africa and runs clinical trials in the UK, Uganda and India.
* A drug called oxytocin was commonly used for abortions at military facilities, Nigerian soldiers and guards told Reuters. The drug, a potent hormone, is not recommended for abortions by the WHO and other experts.
Worldwide, oxytocin is widely and effectively used to induce labor, expel the placenta or stanch post-labor bleeding. During labor, the drug is supposed to be administered carefully through a controlled intravenous (IV) drip, closely supervised by trained medical personnel.
Staff at Nigerian military facilities gave women one or more intramuscular injections of oxytocin in quick succession to induce abortion, according to soliders and documentation. “Sudden uncontrolled injections risk uncontrolled and continuous contraction of the uterus, which could lead to the uterus rupturing, resulting in catastrophic internal bleeding and grave risk to the woman’s life,” said Benjamin Black, a British obstetrician-gynecologyst who specializes in abortion care.
* Some of the drugs employed in the Nigerian abortion program – misoprostol and mifepristone – are commonly and safely used throughout the world. But the experts cautioned that too high a dosage of these medications later in pregnancy can overstimulate the uterus. Especially for women who have had multiple previous pregnancies, such stress can lead to a rupture.
“If the uterus ruptures, there’s nothing you can do to stop the bleeding other than doing an operation,” Weeks said. “If it occurs out in the bush, the natural outcome is death.”
Overstimulation can also exhaust the uterus so much that it cannot contract enough to stanch bleeding. In this case, as well, women can easily bleed to death if not quickly treated. Reuters could not determine the dosages of misoprostol and mifepristone that women were given by the army.
* Pregnancies in the Nigerian program were also terminated surgically, by manual vacuum aspiration or dilation and curettage (D&C). While surgical abortions by skilled clinicians are typically safe, education and practice are needed. After the first trimester, a fetus will have developed a calcified skull and a larger placenta that must be removed.
“Then it becomes a specialist skill for a specialist doctor,” said Weeks. In contrast with manual vacuum aspiration, which involves suction of fetal tissues, D&C is riskier because it involves scraping the uterine wall. That poses the risk of puncture. The WHO has recommended against using D&Cs for abortions since 2012.
* Some women were advanced in their pregnancies – as many as eight months along. The experts said the risks of complications rise significantly as a pregnancy progresses.
The WHO recommends that women undergoing abortions after 12 weeks’ gestation have immediate access to a healthcare facility and that all patients remain under observation until the fetus and placenta have been cleared from the uterus.
* Especially in military barracks, sources told Reuters, supervision from trained medical professionals during and after abortions was limited. That would leave at-risk women more vulnerable to dire complications – such as heavy bleeding, incomplete abortions or infection.
* Women in the Nigerian abortion program typically were not afforded the right to “informed consent,” according to the accounts of women themselves and soldiers. This requires a health provider to explain a procedure and its risks before seeking permission to perform it. Informed consent is an internationally recognized principle in medicine intended to protect patients’ autonomy and well-being. (Reporting by Libby George and Reade Levinson. Edited by Julie Marquis.)
