Reproductive health and human rights.

Reproductive health programs should adopt an approach based on human rights at the levels of clinical management as well as national policy, especially those programs responsible for abortion and post-abortion care. Resource-poor women face greater maternal mortality and morbidity, suffer continuous risk because of a lack of access to adequate reproductive health services, and are likelier than more affluent women to resort to unsafe, inaccessible, and/or unaffordable abortion services. The public health and medical communities are highly effective when providing safe abortion procedures and treatment in the event of complications. Efforts must be continued to develop strategies to prevent unwanted pregnancies, unsafe abortions, and abortion-related deaths; to treat abortion complications; to broaden the types of medical and health professionals who are allowed to perform abortions; and to enhance training for abortion providers.     

Induced abortion: What's happening in rural Bangladesh

This qualitative study was done in rural Bangladesh among the women seeking abortion-related care at six health facilities in two rural sub-districts of Bangladesh in 1996–1997. It looked at contraceptive use, why women had abortions, who made the abortion decision, who provided the abortions, the complications of abortion that developed, where and how soon the women sought treatment. A majority of the women in this study availed abortion services from facilities where MR is provided. However, a quarter of the abortion procedures were dangerous or inadequate, and the number of women who developed complications was very high (43 per cent). Only 58 of 143 women attended only one provider, while 85 went on to attend a second provider. Of the 85, 37 went on to a third provider and 4 women had to be referred on to the district hospital with serious complications, of whom one died. About three-quarters of the women were not using contraception at the time of getting pregnant. Many of the dangerous abortions were the most expensive to obtain, not least because of the cost of treatment for complications. Accessibility and availability of menstrual regulation and family planning services need to be strengthened in rural Bangladesh, and training for MR service needs to be improved, along with awareness-raising on the risks of unsafe procedures in the community.     

Safe abortion: WHO technical and policy guidance.

In 2003, the World Health Organization published its well referenced handbook Safe Abortion: Technical and Policy Guidance for Health Systems to address the estimated almost 20 million induced abortions each year that are unsafe, imposing a burden of approximately 67 thousand deaths annually. It is a global injustice that 95% of unsafe abortions occur in developing countries. The focus of guidance is on abortion procedures that are lawful within the countries in which they occur, noting that in almost all countries, the law permits abortion to save a woman's life. The guidance treats unsafe abortion as a public health challenge, and responds to the problem through strategies concerning improved clinical care for women undergoing procedures, and the appropriate placement of necessary services. Legal and policy considerations are explored, and annexes present guidance to further reading, international consensus documents on safe abortion, and on manual vacuum aspiration and post-abortion contraception.     

Abortion-related mortality in a tertiary medical centre in Enugu, Nigeria.

This study reviewed abortion-related maternal deaths, from January 2000 to December 2005 at the University of Nigeria Teaching Hospital, Enugu, Nigeria, to identify maternal characteristics, abortion types, provider characteristics, complications and causes of death. Abortion was defined as termination of pregnancy before 28 completed weeks of pregnancy. There were 93 pregnancy-related deaths, and 11 were abortion-related. Abortion-related mortality accounted for 11.8% of all maternal deaths. Nine (81.8%) had induced abortions; three (27.3%) were teenagers; five (45.5%) were married; and six (54.5%) were unmarried. Five (45.5%) of the women were nulliparous. Six (54.5%) of the procedures were in private medical clinics. The cause of death was sepsis and haemorrhage in eight (72.7%) and three (27.3%) of the women, respectively. Abortion-related mortality is a major contributor to maternal mortality in our institution, with induced unsafe abortion constituting the bulk of the burden. Improved access to family planning and reproductive health services may reduce abortion-related maternal deaths.     

Spontaneous abortion-related deaths among women in the United States--1981-1991.

OBJECTIVE: To examine trends in spontaneous abortion-related mortality and risk factors for these deaths from 1981 through 1991. METHODS: We used national data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System to identify deaths due to spontaneous abortion (less than 20 weeks' gestation). Case-fatality rates were defined as the number of spontaneous abortion-related deaths per 100,000 spontaneous abortions. We calculated annual case-fatality rates as well as risk ratios by maternal age, race, and gestational age. RESULTS: During 1981-1991, a total of 62 spontaneous abortion-related deaths were reported to the Pregnancy Mortality Surveillance System. The overall case fatality rate was 0.7 per 100,000 spontaneous abortions. Maternal age 35 years and older (risk ratio [RR] 1.7, 95% confidence interval [CI] 0.9-3.0), maternal race other than white (RR 3.8, 95% CI 2.2-5.9), and gestational age over 12 weeks (RR 8.0, 95% CI 4.2-11.9) were risk factors for death due to spontaneous abortion. Of the 62 deaths, 59% were caused by infection, 18% by hemorrhage, 13% by embolism, 5% from complications of anesthesia, and 5% by other causes. Disseminated intravascular coagulation (DIC) was an associated condition among half of those deaths for which it was not the primary cause of death. CONCLUSION: Women 35 years of age and older, of races other than white, and in the second trimester of pregnancy age are at increased risk of death from spontaneous abortion. In addition, DIC complicates many spontaneous abortion cases that end in death. Because spontaneous abortion is a common outcome of pregnancy, continued monitoring of spontaneous abortion-related deaths is recommended.     

Delay in the provision of adequate care to women who died from abortion-related complications in the principal maternity hospital of Gabon

Deaths resulting from unsafe induced abortions represent a major component of maternal mortality in countries with restrictive abortion laws. Delays in obtaining care for maternal complications constitute a known determinant of a woman’s risk of death. However, data on the role of delays in providing care at health care facilities are sparse. The association between the cause of maternal death (abortion versus post-partum haemorrhage or eclampsia) and the time interval between admission to hospital and the initiation of treatment were evaluated among women who died at the Maternité du Centre Hospitalier de Libreville, Gabon, between 1 January 2005 and 31 December 2007. The women’s characteristics and the time between diagnosis of the condition that led to death and the initiation of treatment were compared for each cause of death. After controlling for selected variables, the mean time between admission and treatment was 1.2 hours (95% CI: 0.0?5.6) in the case of women who died from post-partum haemorrhage or eclampsia and 23.7 hours (95% CI: 21.1?26.3) in the case of women who died of abortion-related complications. In conclusion, delay in initiating care was far greater in cases of women with complications of unsafe abortion compared to other pregnancy-related complications. Such delays may constitute an important determinant of the risk of death in women with abortion-related complications.     

A risk reduction strategy to prevent maternal deaths associated with unsafe abortion.

INTRODUCTION: Worldwide, 13% of maternal deaths are caused by complications of spontaneous or induced abortion, 29% in Uruguay and nearly half (48%) in the Pereira Rossell Hospital. PURPOSE: This paper describes a risk reduction strategy for unsafe abortions in Montevideo, Uruguay, where over one-fourth of maternal deaths are caused by unsafe abortion. METHODS: Although abortion is not legal in Uruguay, women desiring abortions can be counseled before and immediately after to reduce the risk of injury. Women contemplating abortion were invited to attend a "before-abortion" and an "after-abortion" visit at a reproductive health polyclinic. At the "before-abortion" visit, gestational age, condition of the fetus and pathologies were diagnosed and the risks associated with the use of different abortion methods (based on the best available scientific evidence) were described. The "after-abortion" visit allowed for checking for possible complications and offering contraception. RESULTS: From March 2004 through June 2005, 675 women attended the "before-abortion" and 495 the "after-abortion" visit, the number increasing over time. Some women (3.5%) decided not to abort, others were either not pregnant, the fetus/embryo was dead or the woman had a condition that permitted legal termination of pregnancy in the hospital (7.5%). Most women, however, aborted. All women used vaginal misoprostol in the doses recommended in the medical literature. There were no serious complications (one mild infection and two hemorrhages not requiring transfusion). CONCLUSION: The strategy is effective in reducing unsafe abortions and their health consequences.     

Maternal and abortion related deaths in Bangladesh, 1978-1979

The incidence and causes of pregnancy-related deaths are unknown for most of Asia; only local area studies have been done for Bangladesh. Between December 1978 and May 1979, we interviewed 118 health workers in 63 hospitals and 732 non-hospital facilities to identify case reports of maternal and abortion-related deaths in Bangladesh. Of 1933 pregnancy-related deaths identified, 498 (25.8%) were due to induced abortion. Abortion mortality rates varied significantly in the 18 administrative districts; the highest were in Dinajpur and Chittagong, the most northern and southern districts, and the lowest in Comilla and Noakhali. We used an earlier study of maternal mortality to estimate that about 21,600 pregnancy-related deaths occur each year in Bangladesh. We estimate that about 7.5% of all pregnancy-related deaths were identified in this survey. We infer from these data that safe and effective fertility control, including abortion performed by adequately trained health workers in both in- and out-patient facilities, might be the most appropriate first step in preventing pregnancy-related deaths in Bangladesh.     

Programme's research on determinants of abortion has impact on policy

Induced abortion remains a relatively uncharted research topic in medical demography, social science, and to a lesser extent, in epidemiology. Up to 20% of the 500,000 maternal deaths which occur annually throughout the world, however, may be a consequence of complications of unsafe abortion procedures. The UNDP/UNFPA/WHO/World Bank Special Program of Research, Development, and Research Training in Human Reproduction started a number of studies in 1989 in developing countries on the determinants and consequences of induced abortion. The program's research has produced a wealth of data, with many countries taking important steps to change abortion policy in the interest of improving reproductive health. For example, a study in Mauritius of women hospitalized for abortion revealed that 20% of them had not been using a method of contraception when they became pregnant; a motion was subsequently tabled in the National Assembly to decriminalize abortion. Another study in Chile showed the incidence of induced abortions to be generally under-reported by women and that interventions based upon sound policy can reduce their incidence and improve reproductive health.     

Comparison of women having clandestine and hospital abortions: Maputo, Mozambique

In Mozambique a Ministry of Health decree since 1981 allows public hospitals to carry out abortions if pregnancy results from contraceptive failure or places a woman's health or life at risk. As a result the number of hospital abortions has increased and the number of women attending hospital for complications of clandestine abortion has decreased. Nevertheless, clandestine abortions continue to cause maternal deaths and morbidity. This study compared women attending the main hospital in Maputo for complications of clandestine abortion and those having an induced abortion in the hospital. Most of those in the first group were young and primigravida, had experienced fewer abortions and lived in poorer socio-economic conditions. Fewer had a steady partner, were more frequently recent migrants to Maputo, and had lower knowledge and use of contraceptives. To reduce the number of illegal abortions and their consequences, governmental programmes should aim to make contraceptive and abortion services more available and accessible, particularly to young, unmarried women of low socio-economic status.     

Abortion: A public health problem in Myanmar

Complications following illegally induced abortions have been recognised as an important cause of mortality and morbidity in Myanmar. Based on a review of various studies, and comparing data from the 1970s and 1980s with data since 1990, this paper presents an overview of the problem of induced abortion in Myanmar. Maternal deaths have decreased dramatically since the 1970s in relation to pregnancy and childbirth, but remain very high for abortion complications. The causes of abortion-related deaths have changed very little. A majority of the women in all studies were married, had one or more children and belonged to low income groups. Women were aware of the risks of clandestine abortion but contraceptive prevalence in Myanmar is only 34 per cent in urban areas and 10 per cent in rural areas, and the contraceptive failure rate among women using a method is high. Women's experience and perceptions of abortion are also described. Information and counselling as well as better access to effective contraception could help to reduce abortion-related morbidity and mortality.     

WHO guidelines and the role of the physician in task sharing in safe abortion care

Globally, many women undergo unsafe abortion, although abortion is extremely safe when done in accordance with recommended guidelines. Hence, many women suffer from abortion-related complications, and unsafe abortion remains a major cause of maternal mortality. The high percentage of unsafe abortion is attributed to the inability of women to access safe abortion services. A critical barrier to access is the lack of trained providers. To address this problem, task sharing and the expansion of health worker roles in abortion care have become a public health strategy to mitigate health worker shortages and reduce unsafe abortion. This chapter provides an overview of the WHO guidance on task sharing in safe abortion care, discusses the special role of physicians, and highlights the complexity of implementing task sharing by analyzing the findings from six country case studies.     

Unsafe abortion: worldwide estimates for 2000

Unsafe abortion is preventable and yet remains a significant cause of maternal morbidity and mortality in much of the developing world. Over the last decade, the World Health Organization has developed a systematic approach to estimate the regional and global incidence of unsafe abortion. Estimates based on figures around the year 2000 indicate that 19 million unsafe abortions take place each year, that is, approximately one in ten pregnancies ended in an unsafe abortion, giving a ratio of one unsafe abortion to about seven live births. Almost all unsafe abortions take place in the developing world. In Latin America and the Caribbean, 3.7 million unsafe abortions are estimated to take place each year, with an abortion rate of 26 per 1000 women of reproductive age, almost one unsafe abortion to every three live births. Asia has the lowest unsafe abortion rate at 11 per 1000 women of reproductive age, but 10.5 million unsafe abortions take place there each year, almost one unsafe abortion to every seven live births. However, excluding East Asia, where most abortions are safe and accessible, the ratio for the rest of Asia is one unsafe abortion to five live births. In Africa, 4.2 million abortions are estimated to take place per year, with an unsafe abortion rate of 22 per 1000 women, or one unsafe abortion per seven live births. In contrast, there is one unsafe abortion per 25 live births in developed countries.     

Abortion in a restrictive legal context: the views of obstetrician-gynaecologists in Buenos Aires,Argentina

In Argentina, unsafe abortions are the primary cause of maternal mortality, accounting for 32% of maternal deaths. During reform of the National Constitution in 1994, the women's movement effectively resisted the reactionary government/church position on abortion. Health professionals, including obstetrician-gynaecologists, played conflicting roles in this debate. This article presents results from a study carried out in 1998-1999 of the views of 467 obstetrician-gynaecologists from public hospitals in Buenos Aires and its Metropolitan Area, focus group discussions with 60 of them, and interviews with heads of department from 36 of the hospitals. The great majority believed abortion was a serious public health issue; that physicians should provide abortions which are not illegal; that abortion should not be penalized to save the woman's life, or in cases of rape or fetal malformations; and that women having illegal abortions and abortion providers should not be imprisoned. Some 40% thought abortion should not be penalized if it is a woman's autonomous decision. Those who were better disposed towards the de-penalization of abortion cited a combination of public health reasons and the need for social equity. The women's health and rights movement should do advocacy work with this professional community on women's needs and rights, given the prominent role they play in reproductive health care provision and in the public sphere.     

Unsafe Abortion: Global and Regional Incidence,Trends, Consequences,and Challenges

ObjectiveThis review aims to provide the latest global and regional estimates of the incidence and trends in induced abortion, both safe and unsafe. A related objective is to document maternal mortality due to unsafe abortion. The legal context of abortion and the international discourse on preventing unsafe abortion are reviewed to highlight policy implications and challenges in preventing unsafe abortion.Methods and Data SourcesThis review is based on estimates of unsafe abortion and maternal mortality ratios. These estimates are arrived at using the database on unsafe abortion maintained by the World Health Organization. Additional data from the Demographic and Health Surveys and the United Nations Population Division are used for further analysis of abortion and mortality estimates.ResultsEach year 42 million abortions are estimated to take place, 22 million safely and 20 million unsafely. Unsafe abortion accounts for 70 000 maternal deaths each year and causes a further 5 million women to suffer temporary or permanent disability. Maternal mortality ratios (number of maternal deaths per 100 000 live births) due to complications of unsafe abortion are higher in regions with restricted abortion laws than in regions with no or few restrictions on access to safe and legal abortion.ConclusionLegal restrictions on safe abortion do not reduce the incidence of abortion. A woman’s likelihood to have an abortion is about the same whether she lives in a region where abortion is available on request or where it is highly restricted. While legal and safe abortions have declined recently, unsafe abortions show no decline in numbers and rates despite their being entirely preventable. Providing information and services for modern contraception is the primary prevention strategy to eliminate unplanned pregnancy. Providing safe abortion will prevent unsafe abortion. In all cases, women should have access to post-abortion care, including services for family planning. The Millennium Development Goal to improve maternal health is unlikely to be achieved without addressing unsafe abortion and associated mortality and morbidity.     

Legal abortion mortality in the United States: 1972 to 1982

Between 1972 and 1982, 186 women died as a result of legal abortion in the United States. The overall death rate resulting from legal abortion dropped nearly fivefold, from 4.1 per 100,000 abortions in 1972 to 0.8 in 1982. Women who were older, black, of high parity, and had abortions at a later gestational age were at increased risk of death throughout the 11 years of surveillance. During this period, the death rate decreased for abortions at all stages of gestation; the greatest decrease was with abortions performed during the second trimester. For the entire interval, mortality rates were highest for abortions performed by hysterotomy or hysterectomy and lowest for abortions performed by curettage. Before 1977, the most common causes of abortion-related death were infection, hemorrhage, and general anesthesia complications, respectively. Thereafter, hemorrhage became the most common cause of abortion-related death, followed in number by general anesthesia complications. Our findings suggest that there has been a marked decrease in septic legal abortion deaths, but potentially preventable deaths from general anesthesia and hemorrhage remain an important concern. Use of general anesthetics during first-trimester abortions should be carefully reviewed.     

Unsafe abortion and postabortion care - an overview

Forty per cent of the world's women are living in countries with restrictive abortion laws, which prohibit abortion or only allow abortion to protect a woman's life or her physical or mental health. In countries where abortion is restricted, women have to resort to clandestine interventions to have an unwanted pregnancy terminated. As a consequence, high rates of unsafe abortion are seen, such as in Sub-Saharan Africa where unsafe abortion occurs at rates of 18-39 per 1 000 women. The circumstances under which women obtain unsafe abortion vary and depend on traditional methods known and types of providers present. Health professionals are prone to use instrumental procedures to induce the abortion, whereas traditional providers often make a brew of herbs to be drunk in one or more doses. In countries with restrictive abortion laws, high rates of maternal death must be expected, and globally an estimated 66 500 women die every year as a result of unsafe abortions. In addition, a far larger number of women experience short- and long-term health consequences. To address the harmful health consequences of unsafe abortion, a postabortion care model has been developed and implemented with success in many countries where women do not have legal access to abortion. Postabortion care focuses on treatment of incomplete abortion and provision of postabortion contraceptive services. To enhance women's access to postabortion care, focus is increasingly being placed on upgrading midlevel providers to provide emergency treatment as well as implementing misoprostol as a treatment strategy for complications after unsafe abortion.