In this study comparing Health-Related Quality of Life (HRQoL) between women discharged following treatment for abortion complications and those visiting the hospital for routine obstetric care, we found that abortion complications were associated with a significantly diminished HRQoL, and that this association depended on social support. This is the first study, in a resource-limited setting that attempts to describe the relationship between abortion complications, HRQoL and social support.
Women with abortion complications had lower EQ-5D utility scores and EQ-VAS scores compared to women seeking routine obstetric care, a marker of significantly diminished HRQoL. We also found that higher proportions of women with abortion complications reported either some or severe problems with self-care, usual activity, pain/discomfort and anxiety/depression compared to the women visiting the hospital for routine obstetric care. The largest differences were observed in the pain/discomfort, usual activity and anxiety/depression dimensions, suggesting that these are the main drivers of poorer quality of life. Previous research has shown that undergoing an abortion may be associated with adverse psychological outcomes, including depression, suicide-related admissions, feelings of regret, low self-esteem, substance abuse, and deliberate self-harm . Therefore, one can surmise that complications following an illegally-induced abortion may be associated with more severe sequelae. The impact of abortion complications on physical health has also been described. Women who do not die following an unsafe abortion are at risk of short-term consequences including severe bleeding, vaginal and abdominal injury which often result in hospitalization [4, 5]. These sequelae are associated with impairment in the performance of one’s usual activities, self-care, mobility and pain and discomfort.
In our study, the adverse effects of abortion complications on HRQoL were maintained even after adjusting for potential confounders including age, social support, HIV status and socioeconomic indicators, demonstrated by the significant difference in mean EQ-5D utility score in adjusted models. Social support measures were included in the regression models first as a potential confounder, because lack of social support, especially from immediate family, has been cited as a reason why a woman may seek an abortion . However, lack of social support may also independently be associated with poor health related quality of life. Studies in settings where abortion is legal have shown that social support may lead to improved psychological outcomes following an induced abortion [8, 9]. We therefore extended a similar argument to the treatment of abortion complications, assuming that social support would be protective in the association between abortion complications and HRQoL. On average, women in each group reported similar levels of social support. However, we found that the impact of abortion complications on HRQoL was dependent on the number of people who a respondent listed as providing support (SSQN score) and the level of satisfaction with the support received (SSQS score). Our model suggests a paradoxical effect of SSQN score on the difference in HRQoL between our study groups where a one unit higher average number of people providing social support, was associated with larger mean differences in HRQoL, when comparing women with abortion complications and those visiting the hospital for routine obstetric care. This implies that women treated for abortion complications have worse HRQoL, the larger the average number of people providing social support, when compared to those receiving routine obstetric care. One potential explanation for this finding may result from an inherent desire for confidentiality in this setting of substantial anti-abortion stigma. Women who experience abortion complications might prefer to confide in fewer people, whereas in the comparison group (the routine obstetric participants, for whom there was likely no stigma), having more people in whom to confide is associated with higher utility. On the other hand, the more satisfied a woman was with the support she received, the smaller the difference between the groups in utility scores, suggesting a tendency towards at least similar HRQoL. HRQoL may be better if women experiencing abortion complications were highly satisfied with the support offered by those few people in whom they confide. We find these results plausible in a setting of high religious morality, legal proscriptions, and substantial anti-abortion stigma, all of which might prevent women from wanting to confide in more people.
There are several limitations of this study. First, this is a single-center, cross-sectional study of limited numbers, in one region of Uganda. Therefore, interpretations beyond this setting should be made cautiously. There may be unmeasured cultural factors that might bear on the generalizability of these findings, particularly with respect to the social support structures in place. Although it may be a dynamic measure, we did not investigate the changes in social support that women may experience along the course of pregnancy, undergoing an abortion, during admission or post-discharge for abortion complications, nor in the long term. It is possible that given this setting in which abortion is illegal and carries significant social and religious stigma, the perceptions of support available may change and these changes might be important in elucidating the social mechanisms for coping with an induced abortion and its complications. There are also limitations inherent in the use of EQ-5D and the SSQ Short Form in this setting. First, neither instrument has been validated in this region and no official version was available in the local language for the region (Runyankore). We used an algorithm based on Zimbabwean general population data to compute the EQ-5D utility score, and though we expect this is the best available population equivalent, the groups are likely somewhat different. Finally, this study reports specifically short-term HRQoL.