This is the abstract presentation by Riznawaty Imma Aryanty, which took place as part of 8th session of 10th Asia Pacific Conference on Reproductive and Sexual Health and Rights (APCRSHR10) Virtual, on 28th September 2020, on the theme of "Safe abortion and sexual and reproductive health and rights (SRHR) in Asia and the Pacific". 28 September is also observed as International Safe Abortion Day. C H A I R Amy Williamson, Country Director, Marie Stopes International, Cambodia P L E N A R Y S P E A K E R S * Dr Suchitra Dalvie, coordinator, Asia Safe Abortion Partnership (ASAP) | "Abortion and Reproductive Justice: The Unfinished Revolution" * Sivananthi Thanenthiran, Executive Director, ARROW | "Right to Safe Abortion: putting women at the centre of the discourse and practice" A B S T R A C T P R E S E N T E R S * Katherine Gambir | Is Self-Administered Medical Abortion as Effective as Provider-Administered Medical Abortion? A Systematic Review and Meta-Analysis * Aryanty Riznawaty Imma | Challenges in Recording Abortion Related Complications at Health Facilities in Setting Where Abortion is Highly Restricted * Dr Yaghoob Foroutan | Abortion’s Patterns and Determinants in Iran: Attitudinal Dynamics * Maria Persson | A Qualitative Study on Healthcare Providers’ Experiences of Providing Comprehensive Abortion Care in the Humanitarian Setting in Cox’s Bazar, Bangladesh For more information on this session go to www.bit.ly/apcrshr10virtual8 #SRHR #sexualhealth #reproductiverights #familyplanning #womenshealth #genderequality #SDGs #abortion #MyAbortionMyHealth #28Sept #InternationalSafeAbortionDay #SafeAbortion #BodilyAutonomy

1. Challenges in Recording Abortion Related
Complications at Health Facilities
in Settings Where Abortion is Highly
Restricted
RIZNAWATY IMMA ARYANTY
LEJLA AMIRA SYAHDAN
APCRSHR VIRTUAL SESSION – 28 SEPTEMBER 2020

2. Presentation Outline
 Background
 Objectives
 Data and method of analysis
 Research Settings
 Findings
 Conclusions

3. Background: Abortion in Indonesia
Abortion in Indonesia is permissible only for medical
indications, severe congenital defects and rape cases
(Health Law no 36 of 2009).
Government family planning program is provided only for
married couples (Population Law no 52 of 2009).
Unmet need for contraception 11% among married women
(4% for spacing & 6% for limiting) (IDHS 2017)
The last published study estimating 2 millions cases of
abortion (spontaneous and induced abortion) in Indonesia
in 2000 or 37 per 1000 women aged 15 to 49 years (Utomo,
2001).

4. Objectives
1. To understand the challenges in recording and
reporting of abortion where it is legal for limited
grounds by assessing:
 The patterns of abortion morbidities
 Data completeness
2. To assess the abortion treatment data and pattern
of morbidities using national health insurance data

5. Data and Method of Analysis(1)
In-depth study on abortion hospitalization data in
Yogyakarta of 2009
 Total number of cases with abortion related
diagnosis from the hospitals in Yogyakarta
Province from 1 January to 31 December 2009.
 Selecting variables per case from the medical
records.
 ICD code O01 to O08 as diagnosis for abortion.
 Observation in data recording process

6. Data and Method of Analysis(2)
National Health Insurance (JKN) Data 2015 and 2016
published in 2019
 A sub sample of national health insurance scheme
sample of 489,277 women aged 15-49 years who are
the member of national health insurance (JKN). It was
selected from sample data of 1,697,452 members
provided by Social Insurance Administration Board
(BPJS).
 ICD code O01 to O08 as diagnosis for abortion.
 Analysis: Descriptive analysis.

7. Research Settings: Yogyakarta Province
 Area: 3184 km2
 Population (2009):
3,501,900
 5 districts
 38 hospitals
providing
maternity care
 Represents city
characteristics

8. Trend of TFR: Indonesia and Yogyakarta Province
8
The TFR in Yogyakarta has been has in creased in the past 10 years

9. Trend of CPR: Indonesia and Yogyakarta Province
9
Yogyakarta has the lowest TFR in Indonesia, but contraceptive use tends to
decrease in recent years with continued high reliance on traditional method.

10. Despite the restriction, herbs and drugs for Menstrual Regulation are
widely available
10
Menstrual Regulation refers to methods to establish non-pregnancy,
without prior confirmation of the pregnancy status.
Price range/item:
Rp1500 – Rp 170,000
($1.1- $13)

11. Menstrual regulation drugs are advertised in
local newspaper
11
Is your menstruation late?
Not regular?
1-2 hours, guaranteed success,
safe without side effects
(Guaranteed 100%)
Call: 081904136000
Medicine for late menstruation,
Effective, Safe, No side effects
(MOH), 1-2 hour after use,
Guaranteed 100% Success)
Tel: 0878 3837 3111

12. 12
Data Collection: Number of hospitals (providing maternity
care) in Yogyakarta Province and in the study in 2009
District
Women aged
15 - 49 years
Yogyakarta Study
Public Private Public Private
 Kulon Progo
108,102
1 4 1 3
 Bantul 239,399 1 5 1 3
 Gunung Kidul 161,734 1 2 1 1
 Sleman 189,528 4 11 2 4
 Yogyakarta city 116,242 2 7 2 5
Total 815,006
9 29 7 16
38 23

13. FINDINGS

14. Threatened abortion (Imminent) involves vaginal bleeding with or without cervical
dilatation. Symptoms may resolve and pregnancy may continue. If the symptoms
continue, the pregnancy will result in an inevitable, complete or incomplete
abortion.
Inevitable Abortion (Incipient) involves vaginal bleeding, abdominal cramping &
progressive dilation of cervix, with or without rupture of the membranes. It is
impossible for the pregnancy to continue & eventual expulsion of the products of
conception will occur.
Incomplete Abortion is the partial expulsion of products of conception. All or part
of the placenta may be retained resulting in profuse bleeding. Usually occurs in
the second trimester of pregnancy.
Complete abortion all the products of conception are expelled. More likely to
occur in the first eight weeks of pregnancy
Stages of Abortion Process

15. International Classification of Diseases 10 (ICD 10) for
pregnancy with abortive outcomes
ICD Code Categories
O00 Ectopic pregnancy
O01 Hydatidiform mole
O02 Other abnormal product of conception
O03 Spontaneous abortion
O04 Medical abortion
O05 Other abortion
O06 Unspecified abortion
O07 Failed attempted abortion
O08 Complication following abortion and ectopic and
molar pregnancy

16. Diagnosis of abortion & ICD 10 code in
Yogyakarta, 2010
1.3
97.5
89
2.5
8.9
0.9
0%
20%
40%
60%
80%
100%
Incomplete
abortion
Blighted ovum
O02 - abnormal conception O03 - spontaneous
O06 - unspecified O04/5/7 - others
9.9
6.2
59.5
17.5
6.8
Imminent Incipient
Incomplete Blighted ovum
Other abortion

17. Recording of abortion related complications
 Diagnosis upon admission was referring to abortion process
(imminent, incipient, incomplete)
 ICD 10 coding is done generally by health information staff as a
secondary step based on the information provided in the medical
records.
 Common practice to categorize cases under the spontaneous
abortion category. Almost 90 percent of incomplete abortions are
categorized as spontaneous abortion
 Observation and interviews with health information staff, it was
found that cases of incomplete abortion are often categorized under
ICD code O03.4 as incomplete abortion without complications,
despite the fact that symptoms of spontaneous and induced
abortion are similar

18. Availability of variables from the medical records
100
100
99.4
99.2
97.2
96
94.8
94.2
94.1
91.6
90.7
90.7
88.7
87.2
86.7
86.1
83.6
82.5
82.1
78.6
78.1
77
66.9
65.1
49.5
39.3
36.4
32.4
31.1
0 20 40 60 80 100
Diagnosis
District of residence
Admission date
Age
Treatment
Number of pregnancy
Religion
Class of services
How to access the hospital
Dischaged date
Number of abortion
Number of birth
Gestation
Responsible person
Method of discharged
Marital status
Method of payment
Condition of discharged
Procedure of admission
Occupation
Treatment date
Hemogloblin level
Last menstruation date
Education
Birthdate
ICD 10 Code
Family planning
Antenatal care
Previous pregnancy outcome
Percentage

19. Data completion
 All medical records were paper-based with only a few private
hospitals applied computer-based medical system
 Discrepancy, illegibility of data inscriptions, poor handwriting, lack
of standardization in the use of abbreviations of medical as well as
other general terminologies
 Missing information. data incompleteness.
 Data relating to hospital administration is more available, while data
relating to patients’ previous obstetric history (such as antenatal
care history and the use of family planning methods) less available.
 Birth dates are not well recorded, but a patient’s age is collected as
a substitute.

20. Changes of Context in 2019
 National Health Insurance scheme is launched in 2014. By 2019,
JKN covers 84% population (222 million)
 No change in the law. Abortion is legal for medical emergency
(women and fetus) and rape cases
 Government regulations no 6 of 2014 on Reproductive Health.
Article 31-33 medical indications and rape cases as exceptions to
prohibition of abortion
 Ministry of Health Regulation no 3 of 2016: Training and provision
of abortion care for medical emergency and pregnancy due to
rape
 Misoprostol are widely available through online informal vendors
However, prices are high, no means of verifying a seller’s
legitimacy, inaccuracy and completeness of information, dosage
 Misoprostol is only registered for gastric ulcers in Indonesia

21. 21
Diagnosis of Abortion in Referral Facilities, 2016
Code Diagnosis Referral
Facilities (%)
O020 Blighted ovum and nonhydatidiform mole 36.7
O021 Missed abortion 13.9
O030 Incomplete, complicated by genital tract & pelvic infection 1.3
O031 Incomplete, complicated by delayed or excessive hemorrhage 5.6
O033 Incomplete, with other & unspecified complications 1.9
O034 Incomplete, without complications 29.9
O039 Complete or unspecified, without complication 4.2
O070 Failed medical abortion, complicated by genital tract & pelvic infection 0.1
O080 Genital tract and pelvic infection following abortion/ectopic/molar preg 0.3
O088 Other complication following abortion/ectopic/ molar preg 0.1
O089 Complication following abortion/ectopic/molar preg, unspecified 0.2
Others 5.92
 In total 0.2% women aged 15-49 years has used abortion related treatment,
most of them received it in referral health facilities
 The most common diagnoses: incomplete spontaneous abortion 42.9%

22. Treatment in Referral Health Facilities, 2016
TREATMENT %
Abortion 2
Mild abortion 6.5
Mild antepartum disorder 1.4
Mild abortion procedure 8
Mild curettage, dilatation & curettage 66.8
Moderate curettage, dilatation & curettage 2.1
Gynecological ultrasound 8.1
Other ultrasound 1.5
Others 3.9
The recommended methods for post abortion care or safe abortion in
the early pregnancy is manual or electric vacuum aspiration or
medical abortion.

23. Conclusions
 Almost 90 percent of incomplete abortions are
categorized as spontaneous abortion.
 ICD 10 coding system to distinguish between
spontaneous and induced abortions is problematic in
countries where abortion is illegal or highly restricted 
Women may avoid revealing their attempt to terminate
pregnancy and health staff do not want to risk being
involved with any legal implications
 National Health Insurance data can be used to assess the
situation on treatment of abortion related complications
 computerized, wide coverage

24. Thank you