Cost-effectiveness analysis of alternative first-trimester pregnancy termination strategies in Mexico City

Objective  To assess the comparative health and economic outcomes associated with three alternative first-trimester abortion techniques in Mexico City and to examine the policy implications of increasing access to safe abortion modalities within a restrictive setting.
Design  Cost-effectiveness analysis.
Setting  Mexico City.
Population  Reproductive-aged women with unintended pregnancy seeking first-trimester abortion.
Methods  Synthesising the best available data, a computer-based model simulates induced abortion and its potential complications and is used to assess the cost-effectiveness of alternative safe modalities for first-trimester pregnancy termination: (1) hospital-based dilatation and curettage (D&C), (2) hospital-based manual vacuum aspiration (MVA), (3) clinic-based MVA and (4) medical abortion using vaginal misoprostol.
Main outcome measures  Number of complications, lifetime costs, life expectancy, quality-adjusted life expectancy.
Results  In comparison to the magnitude of health gains associated with all safe abortion modalities, the relative differences between strategies were more pronounced in terms of their economic costs. Assuming all options were equally available, clinic-based MVA was the least costly and most effective. Medical abortion with misoprostol provided comparable benefits to D&C, but cost substantially less. Enhanced access to safe abortion was always more influential than shifting between safe abortion modalities.
Conclusions  This study demonstrates that the provision of safe abortion is cost-effective and will result in reduced complications, decreased mortality and substantial cost savings compared with unsafe abortion. In Mexico City, shifting from a practice of hospital-based D&C to clinic-based MVA and enhancing access to medical abortion will have the best chance to minimise abortion-related morbidity and mortality.     

Destigmatising abortion: expanding community awareness of abortion as a reproductive health issue in Ghana

Traditional and cultural values, social perceptions, religious teachings and criminalisation have facilitated stigmatisation of abortion in Ghana. Abortion is illegal in Ghana except in three instances. Though the law allows for performance of abortion in three circumstances, the Ghana reproductive health service policy did not have any induced legal abortion services component to cover the three exceptions until it was revised in 2003. The policy only had 'unsafe and post-abortion' care components, and abortions performed in health facilities operated by the Ghana Health Service were performed under this component. Though the policy has been revised, women and girls who need abortion services in Ghana more often resort to the backstreet dangerous methods and procedures. Criminalisation of abortion and those who perform abortions has contributed to unsafe abortion, the second leading cause of maternal deaths in Ghana. Most of these are performed outside the formal health service structures. Traditionally, abortion is perceived as a shameful act and the community may shun and give a woman who has caused anabortion derogatory names. Would provision of legal abortion services be culturally acceptable within a Ghanaian community? Yes, if they are made aware of the reproductive health benefits of providing safe abortion services. Three major strategies that would help to destigmatise abortion in the community are (1) the liberal interpretation of the three exceptions to the law on abortion; (2) expanding community awareness of its reproductive health benefits; and (3) improving and increasing access to legal abortion services within the formal health facilities.     

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.     

Contraceptive use, fertility, and unsafe abortion in developing countries.

OBJECTIVES: Despite a substantial rise in contraceptive use around the world, unplanned pregnancies and induced abortion continue to occur. Each year an estimated 19 million abortions are carried out outside the legal system, often by unskilled practitioners or under unhygienic conditions. This paper explores the relationship between contraceptive prevalence and unsafe abortion in developing regions with different levels of fertility. These relationships manifest the extent to which the desire to regulate fertility is addressed by contraception or by unsafe abortion, where access to safe abortion is legally restricted. METHODS: Secondary analysis of estimates of unsafe abortion, total fertility rate and contraceptive prevalence, by geographical regions. RESULTS: High levels of unsafe abortion persist even where contraceptive prevalence is increasing and fertility is declining. It appears that a high dependence on sterilization for limiting family size may by be preceded by reliance on unsafe abortion, where abortion is restricted, for birth spacing. CONCLUSIONS: The reliance on unsafe abortion could be reduced during fertility transition by improving women's access to reversible contraceptives for spacing births as well as to sterilization for terminating childbearing. Expanding contraceptive choices and a balanced method mix can serve as an effective strategy to prevent unsafe abortion where reliance on sterilization to limit childbearing is not preceded by the use of reversible modern methods for spacing and where access to safe abortion is restricted by law. The intriguing association between contraceptive method choice and the incidence of unsafe abortion deserves further exploration.     

Contraceptive use,fertility, and unsafe abortion in developing countries

Objectives Despite a substantial rise in contraceptive use around the world, unplanned pregnancies and induced abortion continue to occur. Each year an estimated 19 million abortions are carried out outside the legal system, often by unskilled practitioners or under unhygienic conditions. This paper explores the relationship between contraceptive prevalence and unsafe abortion in developing regions with different levels of fertility. These relationships manifest the extent to which the desire to regulate fertility is addressed by contraception or by unsafe abortion, where access to safe abortion is legally restricted.

Methods Secondary analysis of estimates of unsafe abortion, total fertility rate and contraceptive prevalence, by geographical regions.

Results High levels of unsafe abortion persist even where contraceptive prevalence is increasing and fertility is declining. It appears that a high dependence on sterilization for limiting family size may by be preceded by reliance on unsafe abortion, where abortion is restricted, for birth spacing.

Conclusions The reliance on unsafe abortion could be reduced during fertility transition by improving women's access to reversible contraceptives for spacing births as well as to sterilization for terminating childbearing. Expanding contraceptive choices and a balanced method mix can serve as an effective strategy to prevent unsafe abortion where reliance on sterilization to limit childbearing is not preceded by the use of reversible modern methods for spacing and where access to safe abortion is restricted by law. The intriguing association between contraceptive method choice and the incidence of unsafe abortion deserves further exploration.     

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.     

Knowledge, attitude and practice of private medical practitioners in Calabar towards post-abortion care

This study examined the knowledge, attitude and practice of private medical practitioners in Calabar on abortion, post-abortion case and post-abortion family planning. Forty eight private practitioners who were proprietors of private clinics in the city were interviewed using a structured questionnaire. The results showed that 22.9% of the doctors routinely terminate unwanted pregnancies when requested to do so by women, while 83.3% of them treat women who experience complications of unsafe abortion. The major reasons given by some of the doctors for not terminating unwanted pregnancies were religious, moral and ethical considerations rather than respect for the Nigerian abortion law. Only 18.2% of the doctors use standard procedures such as manual vacuum aspiration (MVA) for the management of patients with abortion and abortion complications. A good number of them did not routinely practice integrated post-abortion family planning and STDs management. There is need for a comprehensive programme of retraining of private medical practitioners in Calabar on the principles and practices of safe abortion, post-abortion care and family planning. These aspects of reproductive health need to be integrated into the medical training curricula in Nigeria. It is believed that this approach would help reduce the present high rate of abortion-related morbidity and mortality in Nigeria.     

Attitudes and practices of private medical providers towards family planning and abortion services in Nigeria

CONTEXT: The study was designed to investigate the attitudes and practices of private medical practitioners towards abortion, postabortion care and postabortion family planning in Nigeria. METHODS: Three hundred and twenty-three private practitioners who were proprietors of private clinics in three states of the country were interviewed with a structured questionnaire that elicited information on their knowledge and experiences of abortion and postabortion care in the cities. RESULTS: Twenty-four percent of the doctors reported that they routinely terminate unwanted pregnancies when requested to do so by women, while 82% reported that they frequently treat women who experience complications of unsafe abortion. Over 45% reported that they use manual vacuum aspiration (MVA) for the management of abortion in the first trimester, while 25% use dilatation and curettage (D and C). Nearly 28% reported the use of MVA followed by D and C in the first trimester. Fifty-seven percent reported their lack of expertise in managing second-trimester abortions, while those admitting that they manage second-trimester abortions reported nonstandard methods and procedures. In addition, there was evidence of inadequate counseling of women, lack of institutional protocols and poor use of postabortion family planning by the doctors. CONCLUSIONS: These results suggest the need for a program of retraining of private practitioners on the principles and practices of safe abortion, postabortion care and family planning in Nigeria and the integration of these topics into medical training curricula in the country.     

Unsafe abortion in 2008: global and regional levels and trends

Despite the availability of safe and highly effective methods of abortion, unsafe abortions continue to be widespread, nearly all in developing countries. The latest estimates from the World Health Organization put the figure at 21.6 million unsafe abortions worldwide in 2008, up from 19.7 million in 2003, a rise due almost entirely to the increasing number of women of reproductive age globally. No substantial decline was found in the unsafe abortion rate globally or by major region; the unsafe abortion rate of 14 per 1,000 women aged 15-44 years globally remained the same from 2003 to 2008. Modest reductions in unsafe abortion rates were found in 2008 as compared to 2003 in most sub-regions, however. The upward changes in rates in Middle Africa, Western Asia and Central America were due to better coverage and more reliable information in 2008 than in 2003. Eastern and Middle Africa showed the highest rates of unsafe abortion among all sub-regions. Some 47,000 women per year are estimated to lose their lives from the complications of unsafe abortion, almost all of which could have been prevented through better access to sexuality education, fertility awareness, contraception and especially safe abortion services.     

Global progress in abortion advocacy and policy: an assessment of the decade since ICPD

The 1994 International Conference on Population and Development (ICPD) Programme of Action represented a positive step toward legitimising abortion as a component of basic reproductive health services. This paper reviews how the ICPD principles and recommendations have been applied in the past decade toward increasing women's access to affordable, safe and legal abortion services. It examines advocacy efforts to increase understanding of abortion among policymakers and the public, policy and action at the global level, progress made in national-level policies and services, and obstacles encountered. Research and advocacy are helping to break the silence globally about unsafe abortion, and there is an emerging global movement supporting women's right to safe abortion. A great deal has been accomplished in the ten short years since ICPD, in spite of serious setbacks in some countries and continuing obstacles. A synthesis of public health and rights-based approaches, and strategic partnerships with other social justice movements are called for, as a foundation for effective legal reform efforts and to ensure that women have access to safe abortion services.     

Making Abortions Safe: A Matter of Good Public Health Policy and Practice

Globally, abortion mortality constitutes at least 13% of maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high mortality and morbidity from abortion tend to occur together. Preventing abortion mortality and morbidity in countries where they remain high is a matter of good public health policy, based on good medical practice, and an important part of initiatives to make pregnancy safer. This paper examines the changes in policy and health service provision required to make abortions safe. It is based on a wide-ranging review of published and unpublished sources. In order to be effective, public health measures must take into account the reasons why women have abortions, the kind of abortion services required and at what stages of pregnancy, the types of abortion service providers needed, and training, cost and counselling issues. The transition from unsafe to safe abortions demands: changes at national policy level; abortion training for service providers; the provision of services at the appropriate primary level health service delivery points; and ensuring that women access these services instead of those of untrained providers. Public awareness that abortion services are available is a crucial element of this transition, particularly among adolescent and single women, who tend to have less access to reproductive health services generally.     

Complications of unsafe abortion: a case study and the need for abortion law reform in Nigeria

Complications of unsafe abortion account for 30-40% of maternal deaths in Nigeria. This paper reports a case of unsafe abortion by dilatation and curettage, carried out by a medical practitioner in a private clinic on a 20-year-old single girl in Lagos, Nigeria. The girl was 16 weeks pregnant. She suffered complications consisting of perforation of the vaginal wall through the utero-vesical space into the abdominal cavity with gangrenous loops of small intestine herniating through it. Information was obtained from her case notes and the operating theatre register. She had a resection and anastomosis of the small intestine and had to remain in hospital, where she made a full recovery, for two weeks. Unsafe abortion is fraught with many complications, including pelvic sepsis, septicaemia, haemorrhage, renal failure, uterine perforation and other genital tract injuries, and gastro-intestinal tract injuries. Where expert, emergency treatment for these is not available, women die. Unsafe abortion procedures, untrained abortion service providers, restrictive laws and high morbidity and mortality from abortion tend to occur together. We advocate for a review of the existing restrictive laws in Nigeria in order to reduce the high morbidity and mortality from unsafe abortion.     

Unsafe abortion: an avoidable tragedy

An estimated 60 000-70 000 women die annually from complications of unsafe abortion and hundreds of thousands more suffer long-term consequences which include chronic pelvic pain and infertility. The reasons for the continuing high incidence of unwanted pregnancy leading to unsafe abortion include lack of access to, or misuse of and misinformation about, effective contraceptive methods, coerced sex which prohibits women from protecting themselves, and contraceptive failure. Unsafe abortion is closely associated with restrictive legal environments and administrative and policy barriers hampering access to existing services. Vacuum aspiration and medical methods combining mifepristone and a prostaglandin for early abortion are simple and safe. For second trimester abortion, the main choices are repeat doses of prostaglandin with or without prior mifepristone, and dilatation and evacuation by experienced providers. Strategies for preventing unsafe abortion include: upgrading providers' skills; further development of medical methods for pregnancy termination and their introduction into national programmes; improving the quality of contraceptive and abortion services; and improving partner communication.     

Misoprostol and the politics of abortion in Sri Lanka

Misoprostol, a WHO essential medicine indicated for labour induction, management of miscarriage and post-partum haemorrhage, as well as for induced abortion and treatment of post-abortion complications, came up for registration in Sri Lanka in December 2010. The decision on registration was postponed, indefinitely. This has wide-ranging implications, as misoprostol is widely available and used, including by health professionals in Sri Lanka, without guidance or training in its use. This paper attempts to situate the failure to register misoprostol within the broader context of unsafe abortion, drawing on data from interviews with physicians and health policymakers in Sri Lanka. It demonstrates how personal opposition to abortion infiltrates policy decisions and prevents the issue of unsafe abortion being resolved. Any move to reform abortion law and policy in Sri Lanka will require a concerted effort, spearheaded by civil society. Women and communities affected by the consequences of unsafe abortion need to be involved in these efforts. Regardless of the law, women will access abortion services if they need them, and providers will provide them. Decriminalizing abortion and registering abortion medications will make provision of abortion services safer, less expensive and more equitable.     

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.     

Unsafe Abortion: Unnecessary Maternal Mortality

Every year, worldwide, about 42 million women with unintended pregnancies choose abortion, and nearly half of these procedures, 20 million, are unsafe. Some 68,000 women die of unsafe abortion annually, making it one of the leading causes of maternal mortality (13%). Of the women who survive unsafe abortion, 5 million will suffer long-term health complications. Unsafe abortion is thus a pressing issue. Both of the primary methods for preventing unsafe abortion—less restrictive abortion laws and greater contraceptive use—face social, religious, and political obstacles, particularly in developing nations, where most unsafe abortions (97%) occur. Even where these obstacles are overcome, women and health care providers need to be educated about contraception and the availability of legal and safe abortion, and women need better access to safe abortion and postabortion services. Otherwise, desperate women, facing the financial burdens and social stigma of unintended pregnancy and believing they have no other option, will continue to risk their lives by undergoing unsafe abortions.Key words: Unsafe abortions, Maternal mortality, Postabortion careAccording to the World Health Organization (WHO), every 8 minutes a woman in a developing nation will die of complications arising from an unsafe abortion. An unsafe abortion is defined as “a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.”¹ The fifth United Nations Millennium Development Goal recommends a 75% reduction in maternal mortality by 2015. WHO deems unsafe abortion one of the easiest preventable causes of maternal mortality and a staggering public health issue.     

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.     

Access to safe abortion within the limits of the law

The World Health Organization defines unsafe abortion as a procedure for terminating an unintended pregnancy carried out by people lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. The Programme of Action of the International Conference on Population and Development recommends that 'In circumstances where abortion is not against the law, such abortion should be safe'. However, millions of women still risk their lives by undergoing unsafe abortion even if they comply with the law. This is a serious violation of women's human rights, and obstetricians and gynaecologists have a fundamental role in breaking the administrative and procedural barriers to safe abortion. This chapter reviews the magnitude of the problem, its consequences for women's health, the barriers to access to safe abortion, including its legal status, the effect of the law on the rate and the consequences of abortion, the human rights implications and the current evidence on methods to perform safe abortion. This chapter concludes with an analysis of what can be done to change the current situation.     

Self-induction of abortion among women in the United States

Recent media coverage and case reports have highlighted women's attempts to end their pregnancies by self-inducing abortions in the United States. This study explored women's motivations for attempting self-induction of abortion. We surveyed women in clinic waiting rooms in Boston, San Francisco, New York, and a city in Texas to identify women who had attempted self-induction. We conducted 30 in-depth interviews and inductively analyzed the data. Median age at time of self-induction attempt was 19 years. Between 1979 and 2008, the women used a variety of methods, including medications, malta beverage, herbs, physical manipulation and, increasingly, misoprostol. Reasons to self-induce included a desire to avoid abortion clinics, obstacles to accessing clinical services, especially due to young age and financial barriers, and a preference for self-induction. The methods used were generally readily accessible but mostly ineffective and occasionally unsafe. Of the 23 with confirmed pregnancies, three reported a successful abortion not requiring clinical care. Only one reported medical complications in the United States. Most would not self-induce again and recommended clinic-based services. Efforts should be made to inform women about and improve access to clinic-based abortion services, particularly for medical abortion, which may appeal to women who are drawn to self-induction because it is natural, non-invasive and private.