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.     

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.     

Sexual behaviour of young people

20% of the world's population is aged 10-19 years. Annually, almost 15 million young women under age 20 become mothers. However, surveys in developing countries show that 20-60% of the pregnancies and births to women under age 20 are mistimed or unwanted. While later marriage age in many places has provoked a decline in birth rates among young women, levels of sexual relations before marriage are increasing. Such sexual behavior opens sexually active young women to the risks of unwanted pregnancies, unsafe abortion, and sexually transmitted diseases (STDs). Millions of young people become infected with STDs annually. Among all age groups in the US, young women aged 15-19 have the highest incidence of gonorrhea among females and young men aged 15-19 have the second highest incidence among males. At least half of all people infected with HIV are under age 25. The UNDP/UNFPA/WHO/World Bank Special Program of Research, Development, and Research Training in Human Reproduction (HRP) completed 9 studies in 1996 on adolescent reproductive health. 14 studies were completed before 1996, and 18 are still underway.     

Reproductive health characteristics of young Malawian women seeking post-abortion care

Abortion is illegal in Malawi except when the pregnancy endangers the mother's life, yet complications of abortion account for the majority of admissions to gynecological wards. This study collected data on all post-abortion care (PAC) cases reporting to all PAC-providing health facilities in Malawi over a 30-day period. Of a total of 2,028 PAC clients, 20.9% were adolescents (age 10-19) and 29.6% were young adults (age 20-24). More than half of adolescents and almost 80% of young adults were married. Less than 5% of adolescents and 22.5% of young adults reported using contraception when they became pregnant. Being unmarried was associated with previous abortion and contraceptive use among young adults. These statistics indicate a high proportion of unwanted pregnancy and lack of access to modern contraception among young women. Programs to increase access to pregnancy prevention services and protect young women from unsafe abortions are greatly needed.     

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.     

Unwanted pregnancies,unwanted births,consequences and unmet needs

Worldwide women have to cope up with heavy burden of unwanted pregnancies, mistimed, unplanned, with risk to their health. Their children and families also suffer. Such pregnancies are root cause of induced abortions (safe/unsafe) and grave consequences. Women, their partners can, for most part, prevent unwanted pregnancies by using contraceptives. However many women either do not use any contraceptive or use methods, with high failure rates. These women account for 82% of pregnancies that are not desired. Remaining unintended pregnancies occur among women who use modern contraceptive, either because they had difficulty using method consistently or because of failure. Helping women, their partner use modern contraceptives effectively is essential in achieving Millennium Development Goals for improving women’s health, reducing poverty. If all women in developing countries use modern contraceptives, there would be 22 million less unplanned births, 25 million fewer induced, 15 million fewer unsafe abortions, 90000 less maternal deaths and 390000 less children losing their mothers. Also making abortion services broadly legal, by understanding size, type of unmet needs, most important by creating awareness in communities can surely help tackle this problem to a large extent.     

Induced Abortion According to Socioeconomic Status in Chile

Study ObjectiveThe Chilean legislation forbids induced abortion, so little is known of the young women who have abortions and what determinants are associated with this practice. In this study we examined the association between adolescents and young women who have had induced abortions and socioeconomic status and compared them with counterparts who reported not having a history of abortion.Design, Setting, Participants, and Main Outcome MeasuresDrawing on the 2015 Chilean National Youth Survey, a population-based sample of general community youth aged 15-29 years, we conducted a study on 2439 sexually active females. Bivariate and multiple logistic regression was used to examine the relationship between participants who had induced abortions and participants that had not according to socioeconomic status (low, middle, high), while controlling for demographic, sexual behavior, and cultural covariates.Results5.15% (n = 129) of participants declared having induced an abortion in the past. Participants with high socioeconomic status had 4.89 (95% confidence interval, 1.44-16.51) higher odds of induced abortion compared with participants with low socioeconomic status. Those with middle socioeconomic status had 1.8 (95% confidence interval, 1.02-3.24) higher odds of induced abortion compared with those with low socioeconomic status. Urban or rural residence, indigenous identification, age of sexual debut, contraceptive use at the time of sexual debut, adolescent pregnancy, and religious and political identification did not correlate with induced abortion rates.ConclusionIn Chile, where induced abortion is legally restricted, a social gradient was found in the chance of having had an induced abortion according to socioeconomic status; adolescent and young women with higher socioeconomic advantage reported more induced abortions compared with those with low socioeconomic status.     

Contraception boom points to break-through in reproductive health

The mean fertility rate in developing countries has fallen from 6.1 to 3.9 between the early 1970s and 1992. Increases in contraceptive use contributed to this decline. In 1965-1970, just 9% of married couples used contraception, but by 1985-1990, 50% did. During the same period, the number of contraceptive users increased from 18 to 217 million. Yet, vast regional differences in the decline in fertility exist. The greatest decline occurred in East Asia, while the smallest took place in sub-saharan Africa. Availability of family planning services contributes to this disparity (95% in East Asia and 9% in sub-Saharan Africa). Contraceptive availability in southeastern Asia and Latin America is 57%, and 54% in southern Asia. Just 60% of the population in developing countries can easily obtain at least one safe, effective, and acceptable family planning method. Couples in East Asian countries, especially China, are more likely to use contraception than couples in developed countries. Further, 71% of people who use contraceptives in China use modern contraceptive methods compared to just 47% in developed countries. Just 1% of Chinese contraceptive users depend on traditional methods, while 24% of developed world contraceptive users depend on them. Nevertheless, about 300 million couples worldwide who want to stop having children do not use any contraception. Almost 50% of the 910,000 daily conceptions are not planned and 25% are unwanted. 150,000 induced abortions occur daily, 33% of which are done in an unsafe manner resulting in 500 deaths. Further, many people do not realize that most women who have an abortion are either married or part of a stable union and are mothers to several children.     

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.     

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.     

Demographic aspects of induced abortion

Every day some 150 000 unwanted pregnancies, close to 53 million in a year, are terminated by induced abortion. One third of these abortions are performed under unsafe conditions, resulting in about 500 deaths every day — or approximately 180 000 in 1 year. The majority of these deaths occur in countries in the developing part of the world, where access to abortion is restricted either by law or because existing services are inadequate. The trend towards liberalisation of abortion started in Europe in the 1930s and continues today. Currently, some 63% of the world's people live in countries where abortion is available on request or where social factors can be taken into consideration when evaluating a woman's request for pregnancy termination. Liberalisation of abortion does not inevitably lead to an increase in the number of abortions, as illustrated by the example of the Netherlands which has the lowest reported abortion rate in the world despite its liberal law. Other factors such as universal sex education in schools and easily accessible family planning services, including services for adolescents and the provision of emergency contraception, influence a country's abortion rate to a much greater extent than the degree of liberalness of its law. This is also reflected by the demographic characteristics of the women who most often utilise abortion. In English-speaking countries, especially the USA, and in Scandinavia, young unmarried women make up the largest proportion of those who obtain abortion and the major challenge in these countries, therefore, is to improve sexual education and contraceptive use and hence reduce unintended pregnancy amongst this group. In most other developed countries, including those in Central and Eastern Europe, that have reliable abortion statistics, and probably also in most of the developing world, married women with children constitute the largest group of abortion users and thus the greatest need here is to provide contraceptive services and supplies and encourage their use. But neither the family planning methods currently available nor the people who use them are perfect, and it would be unrealistic to believe, therefore, that unplanned pregnancy and induced abortion are totally preventable.     

ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Medical management of abortion

According to the U.S. Centers for Disease Control and Prevention, 1.18 million legal abortions were performed in the United States in 1997. Of these, 55.5% were performed at or before 56 days of gestation (calculated from the first day of the last menstrual period [LMP]) (I). Almost 98% of abortion procedures were performed by uterine curettage; all but 1% of these used suction curettage. There were 305 legal induced abortions per 1,000 live births, and the abortion rate was 20 per 1,000 women aged 15-44 years. For the first time in 1997, medical abortions were counted and comprised 0.25% of all abortions; 0.45% of those procedures were performed up to 56 days of gestation. Because of the lack of availability of mifepristone, these procedures mostly represent the use of a combination of methotrexate and misoprostol. Over the past two decades, medical methods of abortion have developed throughout the world and are now used clinically in the United States. This document will present evidence of effectiveness, benefits, and risks of medical methods of abortion and provide a framework for the evaluation and counseling of women who are considering such medical methods.     

Sexual activity in girls under 16 years of age

Summary. Data on pregnancy, abortion, sexually transmitted disease and cervical dysplasia in girls under the age of 16 years were collected from British and American publications. Over half the pregnancies in girls under 16 ended in induced abortion, and those that continued had increased maternal and perinatal mortality, partly due to failure to attend for care. A prospective study in young teenagers found a high rate of fetal loss in pregnancies that followed abortions. Apart from an increased risk of cervical injury, abortion in girls under 20 carried the same risk of complications as for the American population as a whole. The risk of developing carcinoma of the cervix was doubled in women who began sexual activity before the age of 17 and a large survey found that 1.9% of the girls aged between 15 and 19 years had abnormal cervical cytology. Discouraging sexual activity before the age of consent seems to have a medical as well as a moral basis.     

Sexual activity in girls under 16 years of age

Data on pregnancy, abortion, sexually transmitted disease and cervical dysplasia in girls under the age of 16 years were collected from British and American publications. Over half the pregnancies in girls under 16 ended in induced abortion, and those that continued had increased maternal and perinatal mortality, partly due to failure to attend for care. A prospective study in young teenagers found a high rate of fetal loss in pregnancies that followed abortions. Apart from an increased risk of cervical injury, abortion in girls under 20 carried the same risk of complications as for the American population as a whole. The risk of developing carcinoma of the cervix was doubled in women who began sexual activity before the age of 17 and a large survey found that 1.9% of the girls aged between 15 and 19 years had abnormal cervical cytology. Discouraging sexual activity before the age of consent seems to have a medical as well as a moral basis.     

Sexual activity in girls under 16 years of age

Summary. Data on pregnancy, abortion, sexually transmitted disease and cervical dysplasia in girls under the age of 16 years were collected from British and American publications. Over half the pregnancies in girls under 16 ended in induced abortion, and those that continued had increased maternal and perinatal mortality, partly due to failure to attend for care. A prospective study in young teenagers found a high rate of fetal loss in pregnancies that followed abortions. Apart from an increased risk of cervical injury, abortion in girls under 20 carried the same risk of complications as for the American population as a whole. The risk of developing carcinoma of the cervix was doubled in women who began sexual activity before the age of 17 and a large survey found that 1.9% of the girls aged between 15 and 19 years had abnormal cervical cytology. Discouraging sexual activity before the age of consent seems to have a medical as well as a moral basis.     

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.     

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.     

Delay in termination of pregnancy among unmarried adolescents and young women attending a tertiary hospital abortion clinic in Trivandrum,Kerala, India

Unwed pregnancy among adolescents is a disturbing event in Indian belief-systems, and very young motherhood limits girls' social, economic and educational prospects. Girls who seek abortions are always at higher risk for delay in care seeking; this paper looks at the reasons why. It reports the experiences of 34 unmarried adolescent girls and young women, aged 10–24 years, who obtained induced abortion from a tertiary care abortion clinic over a period of seven months in 2004. Ten were below 19 years of age, the rest were 20–24 years. Only eight of the 34 pregnancies were <12 weeks. The reasons for delay were fear of disclosure, lack of any support system and scarcity of resources. In 30 cases, the decision to terminate was made jointly with family members, especially the mother. Only half knew about contraception, of whom two used condoms. Only two of the partners accompanied the girl to the abortion clinic and another two offered some financial support. Because of the conflict between wanting to have sex and feeling guilty about it, these young people experienced terrible distress in the course of unwanted pregnancy. Comparing the adolescents who attended the clinic in 2004 with those we have seen in 2012–2013, the paper shows that as regards the essentials, much has remained the same.     

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.     

Induced abortion in the Nordic countries: special emphasis on young women

BACKGROUND: To analyze the trends in legally induced abortions among women younger than 30 years in the five Nordic countries, Denmark, Finland, Iceland, Norway and Sweden, since the liberalized abortion laws came into force. METHODS: Data stem from national registrations of vital events. Some have been published in the national vital statistics while others have been retrieved for this study. General and age-specific abortion rates are used to analyze the trends. Further, an index has been calculated by dividing the age-specific abortion rates by the Nordic average. RESULTS: The analysis reveals an overall reduction in the general abortion rates in the Nordic countries, apart from Iceland. The rates have been highest in Denmark and Sweden and lowest in Finland since the early 1980s. In the mid-1980s, the abortion rates increased among 15-19-year-old women in Sweden and among 20-24-year-old women in Denmark, Norway and Sweden, followed by a reduction. In Iceland the very low age-specific abortion rates for all age groups under 30 years at the beginning of the study period increased and Iceland had the highest rate for 15-19-year-old women in the late-1990s. CONCLUSIONS: The relatively low abortion rates in Finland demonstrate effective preventive efforts, although the recent increase challenges further studies on the relationship between abortion rates and counseling activities. The rise in abortion rates in Iceland indicate a need for improved sex education, contraceptive services and availability of contraceptive methods for young people.