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.     

Maternal mortality and unsafe abortion

Unsafe abortions refer to terminations of unintended pregnancies by persons lacking the necessary skills, or in an environment lacking the minimum medical standards, or both. Globally, unsafe abortions account for 67,900 maternal deaths annually (13% of total maternal mortality) and contribute to significant morbidity among women, especially in under-resourced settings. The determinants of unsafe abortion include restrictive abortion legislation, lack of female empowerment, poor social support, inadequate contraceptive services and poor health-service infrastructure. Deaths from unsafe abortion are preventable by addressing the above determinants and by the provision of safe, accessible abortion care. This includes safe medical or surgical methods for termination of pregnancy and management of incomplete abortion by skilled personnel. The service must also include provision of emergency medical or surgical care in women with severe abortion complications. Developing appropriate services at the primary level of care with a functioning referral system and the inclusion of post abortion contraceptive care with counseling are essential facets of abortion care.     

The reality of unsafe abortion in a rural community in South India

Though the law in India has permitted medical termination of pregnancy on broad legal grounds for over two decades, unsafe abortions carried out by unqualified providers show no signs of decreasing. A community-based study was undertaken in rural South India to determine the prevalence of induced abortion, women's reasons for seeking abortion, who was providing abortions and whether the procedures were safe or unsafe. A cross-sectional study design was used that included focus group discussions with 88 women and a quantitative survey with 195 married women who had a birth interval of two or more years since their last pregnancy. There was a high prevalence of induced abortion (28 per cent) among the study population, mainly among women who were not using contraception. Most abortions were carried out in the first trimester of pregnancy and unqualified practitioners performed 65 per cent of terminations. The preference for illegal, untrained providers in a country where abortion is legally available exposes the ambiguity in the status of abortion and how inadequacies in legal service provision have served to promote and sustain unsafe providers and practices. An integrated approach to family planning and reproductive health which includes abortion is imperative if the reproductive health status of Indian women is to be improved. The poor utilisation of existing government facilities suggests the need for improving the quality of services, expansion of abortion facilities and the introduction of safer methods of abortion. To do this, a re-examination and re-framing of aspects of the 1971 abortion law is needed.     

The struggle for abortion law reform in Thailand

In Thailand abortion is against the law except in cases of risk to a woman's health or if the pregnancy is the result of rape or other sexual crimes. This paper presents an overview of the history of the abortion debate in Thailand based upon research conducted from 1997-2001 for an ethnographic and historical study. Information was taken from media reports from 1950 in the Thai and English language press, a review of parliamentary records and interviews with 10 key informants. The debate over legal reform started in 1973. A reform bill was passed in 1981 in the House of Representatives but defeated in the Senate, primarily due to the lobbying efforts of Chamlong Srimuang, the leader of a broad-based religious coalition, who has been central in the anti-reform movement since then. The current democratically elected government in Thailand offers the best hope yet for reform, though abortion remains a politically sensitive issue, sensationalized in the press to counter reform efforts. A new advocacy network has recently been formed, including a range of women's organisations, public health advocates, academics and journalists. Current proposals from governmental and medical profession bodies may make abortions available to some women, but most, who seek abortions due to socio-economic and family planning reasons, will continue to have to find abortions by whatever means they can.     

A strategic assessment of the reproductive health and responsible parenthood programme of Buenos Aires, Argentina

Since 1991, Argentina has had provincial reproductive health laws, a far-reaching national programme and strong public consensus in support of reproductive health policies. Nevertheless, the challenges of strengthening public services, increasing the number of programme sites and resisting conservative attacks remain. This article describes an assessment of the reproductive health programme of the city of Buenos Aires, passed in 2000, whose objectives are to prevent unwanted pregnancies and sexually transmitted diseases/HIV and to train health personnel. The programme operates in every public hospital and primary health care centre in the city. The assessment was conducted jointly by the Ombudsperson's Office of Buenos Aires and the Centre for the Study of State and Society (CEDES). Hormonal contraceptives, IUDs and male condoms were mostly available, but emergency contraception, female condoms and other barrier methods were not Some health professionals and service users were knowledgeable about the new laws and the reproductive rights recognised under the law. Over 90% were satisfied with quality of care in service delivery but many professionals described excessive workloads, deficient infrastructure, and shortages of supplies and staff. Wanting help to obtain a tubal ligation was the most frequent reason for the claims lodged with the Ombudsperson's Office, followed by HIV, quality of care, and abortion. Information and training for both health care providers and women's and human rights NGOs was carried out.     

Scaling up post-abortion care in Guatemala: initial successes at national level

This article describes a programme to scale up post-abortion care services in 22 of the 33 public sector district hospitals in Guatemala from July 2003 to December 2004. The main interventions included strengthening the knowledge and technical capacity of staff, expanding post-abortion care, enhancing related infrastructure, distributing informational materials and instituting an abortion surveillance system. A facilitator supported the work through week-long, monthly visits at each hospital. Attention was also devoted to building institutional consensus in support of post-abortion care at government, district hospital and hospital staff levels. During this period, 13,928 women with incomplete abortions were admitted to the 22 hospitals. Use of manual vacuum aspiration for treatment of incomplete first trimester abortion increased from 38% to 68% of cases (p<0.0001). Provision of family planning counselling also increased, from 31% to 78% of women (p<0.0001), and the proportion of women selecting a contraceptive method before leaving hospital from 20% to 49% (p<0.0001). Infection was associated with 71% of the incomplete abortions, of which 90% were septic. There were nine deaths and 768 women suffered severe complications, the level of which remained unchanged during the study period. Guatemala still has much to do to institutionalise post-abortion care fully and reduce deaths and complications, but our efforts to date will be valuable to others.     

Integration of post-abortion care: the role of township medical officers and midwives in Myanmar

Complications of unsafe abortion are a significant cause of maternal morbidity and mortality in Myanmar, and are recognised by the Ministry of Health as a priority. The Department of Health developed a strategy to address the problem of abortion complications by integrating post-abortion care and contraceptive services into the existing township health system. The quality of post-abortion care was assessed by the Department of Health in 2000, using a baseline survey of health providers and post-abortion women in Bago Division. The integration of post-abortion care was led by the Township Medical Officers, who provided monthly in-service training and supervision of health care workers in each township. Hospital-based doctors and nurses, clinic midwives, village midwives and other volunteer health providers, including traditional birth attendants, were all trained. The role of the local clinic midwife was extended to make follow-up home visits to the women with post-abortion complications and provide them with contraception when requested. Preliminary results show positive outcomes. However, donor-funded projects may have a destabilizing effect on township services by diverting attention and resources; donors need to work with government to support its priorities for health care. The future nationwide integration of post-abortion care services into township services should be planned in consultation with Township Medical Officers and midwives, the key providers of these services.     

Meeting health care needs of women experiencing complications of miscarriage and unsafe abortion: USAID's postabortion care program

Each year, an estimated 210 million women become pregnant. Worldwide, more than one fourth of these pregnancies will end in abortion or an unplanned birth. While many abortions may result from the desire to delay or avoid pregnancy, 15% to 20% of pregnancies will end in miscarriage or stillbirth with some causative agents being malaria, HIV/AIDS, and physical violence. Postabortion care (PAC) is needed to provide treatment for complications caused by incomplete or spontaneous abortion and critical family planning counseling and services to prevent future unplanned pregnancies that may result in repeat abortions. In 2003, the United States Agency for International Development (USAID) initiated a 5-year strategy wherein seven countries were provided financial funding and technical assistance. Since 2003, more than 3000 women have been seen in health centers and health posts for PAC services; more than 14,000 community members have received messages on unsafe abortion; family planning, and complications of unsafe abortion and miscarriage; and more than 600 documents were reviewed for inclusion in a global PAC resource package. This package has been used for developing Cambodia's national PAC policy and for developing patient education materials and provider job aids in Cambodia and Tanzania. These promising methodologies will be replicated in other countries.     

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.     

A project to improve the quality of abortion services in Moldova

Abortion has been available legally in Moldova since 1955, and since then the abortion rate has gradually declined. The quality of abortion care remains low, however, and there is a high level of maternal mortality related to unsafe abortion. The goals of the 2005-2015 National Reproductive Health Strategy are to reduce unwanted pregnancy, reduce abortion-related morbidity and mortality, improve access to and quality of abortion care, including the methods of vacuum aspiration and medical abortion. This paper presents information on the current abortion law, policy and services in Moldova. It describes a project whose aim is to improve the quality of abortion services, including the introduction of medical abortion through training of service providers and community education. Manual vacuum aspiration has also recently been introduced. The drugs for medical abortion are officially approved, a clinical study evaluating the efficacy and acceptability of medical abortion in a low-resource setting has been completed, and training of providers has been carried out. However, institutionalisation of medical abortion faces many problems in relation to organisation of service delivery, the higher cost of medical than aspiration abortion, and doctors' reluctance to use new methods.     

Abortion in the moral world of the Cameroon grassfields

Despite high levels of unsafe abortion in Cameroon, remarkably limited attention has been paid to the moral dilemma for women who seek abortions. In-depth interviews were conducted with 65 Cameroonian Grasslands women within a hospital-based study, complemented by participant observation, use of hospital records and interviews with key informants. The paper demonstrates how a hidden moral code on abortion helps women to exercise individual agency despite prevailing moral values. At the same time, women's desire to keep abortion secret can impede adequate medical treatment, which in turn can increase the risk of complications and mortality. Abortion was more often condemned by the women because of the risk to their lives and of infertility rather than for religious reasons or because it is illegal. However, the economic and social realities of everyday life often overrode their fear of complications when they needed to end a pregnancy. The paper concludes that women have already broken through Cameroon's stringent restrictions on abortion through their practice. There is a large gap between what is permitted under the current law, which is colonial in origin, and women's need for legal abortion on broad socio-economic grounds. This calls for reflection on liberalisation of the present law.     

The need for family planning and safe abortion services among women sex workers seeking STI care in Cambodia

In Cambodia, clinics established for the prevention and management of sexually transmitted infections (STIs) in women sex workers do not address other reproductive health services. The aim of this study was to assess the need for more comprehensive sexual and reproductive health services for women sex workers in Cambodia. In January 2000, relevant documents were reviewed, interviews with key informants carried out and group interviews with women sex workers conducted. Medical records from women sex workers were also reviewed and some data collected prospectively in one government STI clinic. Interviews with the women and data from the government clinic indicated that excluding condoms, a very low proportion of women sex workers were currently using a modern contraceptive method--5% of 38 women and 1.6% of 632 women, respectively. Induced abortion was widely used but was perceived to be risky and costly. Data from a mobile team intervention and the government clinic respectively showed that 25.5% (n = 1744) and 21.9% (n = 588) of women sex workers reported at least one previous induced abortion. These findings reveal the need for accessible contraception and safe abortion services among sex workers in Cambodia, and raise the issue of the reproductive rights and reproductive health needs of women sex workers in general.     

Clear and compelling evidence: the Polish tribunal on abortion rights

On 25 July 2001 the Polish Federation for Women and Family Planning organised a Tribunal on Abortion Rights in Warsaw, to publicize the negative consequences of the criminalization of abortion in Poland. A panel of Polish and foreign experts heard the testimonials of seven Polish women's experiences under the 1993 "Anti-Abortion Act". Only two of the seven women were able to tell their stories in person. One died in 2001, at the age of 21, of an unsafe abortion. One is legally blind after having carried her last pregnancy to term. One is in prison for infanticide, which in all likelihood was committed by her boyfriend. National and foreign journalists were in attendance, as well as observers from all walks of life--writers, students, mothers, activists, feminists, husbands. The evidence was clear and compelling. Restrictive abortion laws make abortion unsafe by pushing it underground, endanger women's health, create a climate where even those services that are allowed by law-become unavailable, and contravene standards set by international human rights law. The restrictive abortion law in Poland has not increased the number of births; it has only caused women and their families suffering. The Tribunal brought the issue of abortion into the media prior to an election campaign and galvanised Polish and other Eastern European women's groups to become more active in defence of abortion rights.     

Preventing unsafe abortion: Achievements and challenges of a global FIGO initiative

FIGO established a Working Group on the Prevention of Unsafe Abortion in 2007 and a parallel program or “Initiative” with the same name. The initiative involved 46 FIGO member societies from seven regions: South-Southeast Asia, Eastern-Central Europe and Central Asia, North Africa and Eastern Mediterranean, Eastern-Central-Southern Africa, Western-Central Africa, Central America and Caribbean, and South America. Each society working in collaboration with the corresponding Ministry of Health and other agencies conducted a situational analysis and prepared a plan of action based on the findings. Such plans of action are continuously monitored by annual evaluation of the progress in the implementation at regional workshops. A substantial progress has been achieved in providing legal and safe abortion services, replacing curettage for manual vacuum aspiration or misoprostol and introducing and expanding postabortion contraception with emphasis on long-acting methods, such as IUDs and contraceptive implants.     

Single women's experiences of premarital pregnancy and induced abortion in Lombok, Eastern Indonesia

Induced abortion is widely practiced in Indonesia by both married and unmarried women. This paper draws on ethnographic research, conducted between 1996 and 1998, which focused on reproductive health and sexuality among young single women on the island of Lombok in Eastern Indonesia. While abortion for married women is tacitly accepted, especially for women with two or more children, premarital pregnancy and abortion remain a highly stigmatised and isolating experience for single women. Government family planning services are not legally permitted to provide contraception to single women and their access to reproductive health care is very limited. Abortion providers were highly critical of unmarried women who sought abortions, despite their willingness to carry out the procedure. The quality of abortion services offered to single women was compromised by the stigma attached to premarital sex and pregnancy. Women who experienced unplanned premarital pregnancy faced personal and familial shame, compromised marriage prospects, abandonment by their partners, single motherhood, a stigmatised child, early cessation of education, and an interrupted income or career, all of which were not desirable options. Young women were only able to legitimately continue premarital pregnancy through marriage. In the absence of an offer of marriage, single women necessarily resorted to abortion to avoid compromising their futures.     

Making legal abortion available in Brazil: Partnership in pratice

This article describes the participation of feminist groups who work in the area of women's reproductive health and rights in campaigns for the provision of legal abortion in public hospitals in Brazil. Brazilian criminal law permits therapeutic abortion in cases where pregnancy is the result of rape orposes a serious risk to the life of the woman. Today, as a result of the combined efforts of feminists, health professionals and policymakers, more than 20 hospitals in Brazil are officially permitted to perform therapeutic abortions within the existing law. A model programme has also been developed to train service providers to do legal abortions, where the agreement of a hospital board can be obtained. This training has also improved care for illegally obtained, incomplete abortions in those hospitals but not in hospitals where doctors have not been trained. Problems with lack of access and concerns about the lack ofpublic acceptance of abortion remain. Women not only need the right to abortion but also more services and health professionals who are trained to perform abortions across the whole country.     

Safer sex and reproductive choice: findings from "positive women: voices and choices" in Zimbabwe

Positive Women: Voices and Choices was an advocacy-research project developed by the International Community of Women Living with HIV/AIDS to explore the impact of HIV/AIDS on women's sexual and reproductive lives, challenge the violation of their rights and advocate improvements in policy and services. The project in Zimbabwe, the first one in three countries, was carried out from 1998 to 2001. This article presents selected findings from the Zimbabwe research report. It shows that HIV-positive women were unaware they were at risk before an HIV diagnosis, and that gender norms and economic dependence on husbands/partners restricted women's ability to control their sexual and reproductive lives. Prejudices that HIV-positive women should not be sexually active or have children meant women did not disclose their status to health workers, making it difficult for their needs to be acknowledged or addressed. Condom use was considered inappropriate in marriage. Younger childless women wanted to become pregnant, often in spite of previous miscarriage and stillbirths. Women with several children wanted to avoid further pregnancies, and contraceptive and condom use increased markedly after HIV diagnosis, especially among those attending support groups. Safe abortion was almost entirely inaccessible, though technically the law would have permitted it. Better economic opportunities for women, and integrated pregnancy and delivery care, family planning, STI and HIV-related services are needed which take account of HIV-positive women's needs.     

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.     

Using the right to life to confront unsafe abortion in Africa

Unsafe abortion is one of the leading causes of maternal mortality in Africa. In international human rights law, there are two possible approaches to tackling the problem of unsafe abortion. One is to advocate the right of privacy, which means states must refrain from interfering in women's abortion decisions; the other is to advocate the right to life of women, which stresses the duty of states to take affirmative measures to minimise the consequences of unsafe abortion. African societies are communal and duty is the central element in them. The African Charter on Human and Peoples' Rights reflects communal values by stressing the duty of individuals to help their communities. Unlike other human rights documents, it does not have a right of privacy provision. This paper focuses mainly on the right to life and discusses the interpretation of this right for women, as applied to unsafe abortion, under the International Covenant on Civil and Political Rights. Advocating states' duties in ensuring women's right to life, to minimise the consequences of unsafe abortion, is more consistent with duty-based African communal values than the right of privacy.