This study documented intra-hospital clinical data on the characteristics and outcomes of post-rape pregnancy among adolescent girls in post conflict context in Eastern DR Congo.
We noted that three-quarters of the victims came from rural areas, and most were schooled with a median age of sixteen. Half of the victims accepted the pregnancy after psychological consultation. In reference to the relationship with the perpetrator, the victim was simply acquainted with him at (33%) and unknown in only 26%. The majority of the victims gave birth by vaginal route (~ 75%) and 30% by caesarean section. Postpartum complications included postpartum hemorrhage and soft tissue injury (34%). In addition, 50% developed psychological symptoms during labor. Neonatal asphyxia was found in 10%, prematurity at 22.1%, and intrauterine growth restriction at 7.9%. Neonatal intensive care was required in 21% of births, and neonatal hospital stay was required in 24% of cases.
The findings of this study show some specific characteristics of the population. The age group of minors in this study was between 13 and 17 years. Most of them are schooled and come from rural areas. Several authors [8, 14] demonstrate the frequency of pregnancy in this population. In this current context of recurrent conflict in the Eastern DRC, the rural population live in constant social and health insecurity, complicated by the culture promoting the antiquated practice of child marriages [15]. In fact, health insecurity in rural areas is characteristic and perpetuated by the presence of different militia groups and rebel forces that sustain wars in these areas where rape is used as a weapon [5, 17] Children, young girls, and women are all assaulted without much disparity of age. The objective is to ultimately destroy the current social fabric and promote a thriving future for the new generation [16].
In DRC, any sexual intercourse with an adolescent is considered rape. Sexual assault can be perpetrated without physical violence in most cases and more rarely with violence, even to the point of homicide. In a large proportion of cases, perpetrators may be kind, friendly, and well [9, 18]. In the shadow of our study, the perpetrator were mostly civilians (77.9%), as reported in several other studies [19, 22]. The degree of relationship between the perpetrators and the victim is variable, ranging from a simple acquaintance in 33.6% to a complete stranger in 26.4%. Various authors report the same finding [19, 21]
In this situation, there is a neo-culture that has been established in areas where the victims originate. The profile of the perpetrators has changed over time. Currently, former rebels and demobilized militia are returning to the community as civilians and continuing their violent practices. Unfortunately, the lack of justice continues to maintain this culture. A study in Ituri [23] also found that perpetrators of child rape were civilians (81%) and known by the family (74%) in many instances. Nelson [24] described the profile of perpetrators and assaults as isolated incidents during the day and as gang rape.
In our study, the pregnancy was considered at risk; thus, the prenatal consultations required a strict follow-up by a psychologist and obstetrician as recommended by WHO [25]. However, only 74.3% of victims received complete orientation on labor preparation. We noted 20% of attempted termination. The most common characteristics of pregnancies with attempted termination included: unplanned pregnancy and assault by an unknown perpetrator, which included physical coercion. It is important to note that some women came to the hospital with pregnancies that had already progressed, while others did not adhere to the scheduled appointments for their follow-up. Some of them accepted this pregnancy and perceived it as normal due to a solid relationship with the perpetrator (acquaintance, intimate partner, or ex-partner).
The Maputo Protocol authorizing medical abortion in cases of sexual violence should be implemented in the DRC [26]. This would avoid the psychological support of maintaining the pregnancy. Previous studies [6, 27] also indicate attempted abortions in cases of rape or unwanted pregnancy. Unfortunately, in these practices, the methods used to terminate pregnancies are not based on evidence. One study [6] revealed that women often use herbs or drugs to induce an abortion obtained through informal health care networks, either through a friend, family member, or traditional healer. Indeed, according to current Congolese law, abortion services cannot be provided even when requested by the woman or her family in such circumstances [27].
The primary route of delivery was vaginal delivery (69.3%), followed by caesarean section (30.7%). This rate of cesarean delivery in our study is high compared to the finding of Nerum and al. in his study (18%). Indeed, cesarean section rates differ between countries [28] For Karatasli and al (2019), pregnant adolescents have higher cesarean section rates. However, with no statistically significant difference between the adolescent and adult groups [28] compared with adults, the rate of cesarean section is lower among adolescents [13, 30].
The incidence of preterm delivery has been the subject of several studies [29, 30] Adolescents aged 15 to 19 years are at higher risk of preterm birth and a low-birth-weight foetus. This is because the physical immaturity of the uterus causes prematurity. In addition,, psychological instability is also significant in young mothers [31].
This is important to emphasize because the wishes of these women during pregnancy, labor, and postpartum must be considered. As reported in the study [9], women with a history of sexual trauma during the prenatal period want this to be communicated to members of the delivery care team. During the intrapartum period, they want to have control over who is present and how their bodies are displayed in the labor room. They want health care providers to avoid language that leads to recall of previous trauma, and their preference for the gender of the provider should be met. Finally, some women with a history of sexual trauma find breastfeeding challenging but empowering during the postpartum period [9].
Our findings show several maternal morbidities, such as perineal tears (64.6%), especially 2nd degree (64.5%), and perineal lacerations (31.3%).The high prevalence of perineal tears in post-rape minors in our study should be noted. Suna Yıldırım in Turkey found a low rate of perineal tears among adolescents [32] while In Lubumbashi, a study [31] reported no statistically significant difference between adolescent girls and adults in the prevalence of soft tissue tears, with a rate of 10% among adolescent girls. In fact, another study conducted in France reported that the rate of vaginal tears was statistically higher in adolescents than in adults (14.7% vs. 3.9%). However, there was no difference in the rate of perineal tears between the two groups (adolescents vs. adults) [33]. A study in Mexico and Cameroon [33, 34] indicated that adolescents were the most affected by perineal trauma, with no difference in risk factors related to the grade of tear and age.
The rate of neonatal asphyxia in our study population was 9.6%, and 24.3% admission to the neonatal intensive care unit. Several other studies [36, 37] have found almost similar results. Psychological symptoms were identified during labor in our population (52.9%). The frequent signs identified were agitation (10.7%) and hypersensitivity (8.6%). During labor, it in post-rape pregnancies. Sobel and al [10] report signs of anxiety, fear, and reliving trauma during vaginal examination.
WHO wishes to see deliveries in a safe environment [38], and supportive psychotherapy should be continuous even during labor, especially in this category of patients. This in-hospital study has considered adolescent girls with a pregnancy resulting from rape from the time of arrival at the hospital until delivery in a context of conflict. This phenomenon has a legal connotation concerning Congolese legislation and/or narrative. The follow-up was performed in a center of excellence for the care of victims of rape and sexual violence. However, this study is limited by its mono-centric approach.