Discussion

Early and late complications do occur with or after SA or IA, either because abortions are managed by untrained persons or at unsafe places or by unsafe modes or because of inherent problems like bleeding in relation to abortion which can occur anytime, irrespective of person performing or place of abortion. Even a woman with SA can have heavy bleeding, long termsequlaeand recurrence too. Complications also depended on the duration ofpregnancy which got aborted. The concept of post/peri abortion care (PAC) has evolved in the recent past. It is a global approach towards reducing the maternal mortality and morbidity due to complications of SA and IA with various medical and social interventions to ensure improvements in women’s sexual and reproductive health4. The essential elements of PAC include emergency treatment of incomplete abortion, bleeding, infection, fever, pain as well as contraceptive counseling with desired services and linkage to other emergency services. However, the mortality and morbidity risks associated with safe or unsafe IA not only depended on the availability and quality of abortion care, but also on woman’s beliefs, willingness and ability to seek services. Ganatra et al5 reported that around 25 million unsafe abortions (45% of all abortions) occurred between 2010 and 2014 every year worldwide. The majority of unsafe abortions (97%), were in developing countries (Africa, Asia and Latin America). WHO also reported that 19 of every 20 unsafe abortions took place in less developed regions of the world6 and this was where 98% of abortion-related deaths occurred7.So women’s perceptions, beliefs and health seeking matter a lot. Estimated 6.8 million abortions occurred every year in South Central Asia, at a rate of 17 unsafe abortions per 1000 women8. Systematic analysis of 417 data sets from 115 countries estimated the prevalence of maternal deaths from abortive outcomes (ectopic pregnancy inclusive) as 8%. Overall, sub‐SaharanAfrican countries had the highest contribution to maternal deaths due toabortive outcomes9. Haddad et al10 also reported that worldwide 47000 women died due to complications of unsafe abortions, representing 13% of pregnancy related deaths. Review of various studies by Johnston11 revealed that nearly 18% of all maternal deaths in India, were abortion related. Present community based study of magnitude of SA or IA, related complications, care sought by rural tribal women of two Districts of Maharashtra, India, was carried out to know the community based burdeon of abortion complications. There were access problems, lack of resources, lack of awareness, scarce health services, and also quite a few things were not obvious in Dharni Block of Melghat, hilly forestry region with extreme poverty. However overall 3.3% women reported complications in relation to SA in Sewagram region and0.3% women of Dharni Block,10 times less. In Sewagram region care providers were family members, medical officers, specialists, traditional birth attendants and ASHAs in 62%, 25%, 12%, 2% and 1% respectively. Overall 12.5% of the 24 women who had complications were managed at home and 66.7%, 12.5%and 8.34% were managed at Private hospitals, Medical colleges and District hospital respectively. Care seeking seemed to be related to awareness, resources, access to available facilities and beliefs also. Family members were care providers for those who remained at home and the rest 22.5% were managed by medical officers and only 3.75% by specialists at health facilities. Abortion is usually kept secret and so private servicesaresoughtmoreoften.Inthesevillagestribalwomensoughtprivate services even with extreme poverty. It is essential for policy makers to know this aspect of abortion care. In a study, at least 9% of abortion-related hospital admissions had a near-miss event and around 1.5% ended in death10. Hemorrhage was the most common complication reported. The pooled percentage of abortion- related hospital admissions with severe hemorrhage was 23%, with around 9% having near-miss morbidity due to hemorrhage. Results suggested that a substantial percentage of abortion related hospital admissions had potentially life-threatening complications. Present study revealed that in rural community, 1% women reported complications with IA in the form of heavy vaginal bleeding and pain in abdomen in Sewagram region and 0.16% in Melghat region. Not very high numbers. These eventful IA in Sewagram region were cases performed at private hospitals, either for spacing (29%) or for health reasons (71%) and were conducted by medical means in 71%, and surgical procedures in 28%. Whatever was easily available was used was obvious. However there were no major problems reported. No one seemed to have complications to cause near miss or even severe illness. There was no abortion related death in these villages during the whole duration. A lot of research is needed about practices, specially because there were no major complications. Further more women with pregnancy of 10-13 weeks had complications. It is a grey zone. At this gestation medical methods are not used and surgical procedures are likely to cause trauma. It is known that second trimesterIAcarriedahigherriskofcomplicationsbuttheycontinuedinthisregion. However dangerous complications did not occur even in these women. With FGDs it was obvious that there was lack of awareness about possible complications. In a study it was found that in seven of ten countries, less than 10% of primary level facilities could provide basic PAC, and in eight of ten countries less than 40% of referral-level facilities could provide comprehensive PAC12. In the present analysis, not many complications were reported and no services were sought by many even for complications. Primary Health centre, subcentre did not provide PAC. In a study 7.9% women experienced complications13. Case fatality rate was worst for abortion‐related infections (19.1%). In the present study most common post-abortion complications reported were excessive vaginal bleeding and lower abdominal pain but neither in many women,nor heavy. They did not lead to severe illness or near miss morbidity. Other less frequent complications were high grade fever, foul smelling discharge, backache and weakness, probably infection related but still did not lead to severe illness. A community-based study in Madhya Pradesh, revealed that more than one out of two IA among rural women (57%) and more than two of five IA among urban women (46%) resulted in at least one complication14. It was not found in the present study which was community based in villages with extreme poverty. Whatever information was possible verbally was collected and analyzed. There were no records. Because of linkage with maternal services information about severe illness, near miss cases, maternal deaths due to any reason was available. So it was obvious that in this region there were not many problems in abortion cases. Doorman et al15 reported thatindigenous people and local communities (IPLCs) knowledge and practices rely on holistic and integrative conceptualizations of nature and value systems acknowledging interlinked human-nature relations. IPLCs hold a body of knowledge that has been accumulated through generations within their specific cultural and environment context. Using knowledge systems as equal partners informing one another requires bridging them, rather than synthesizing them. Knowledge co- production as a dialog and partnership can harness the practical wisdom and cultural values of IPLCs towards innovative solutions.Conclusion Awareness is needed about abortion complications. Also a lotof research is needed about traditional medicine, reverse pharmacology and sociobehavioural aspects too.