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.     

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.     

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.     

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.     

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.     

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.     

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 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.     

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.     

Unsafe abortion: a neglected tragedy. Review from a tertiary care hospital in India

AIM: With 16% of the world's population, India accounts for over 20% of the world's maternal deaths. The maternal mortality ratio, defined as the number of maternal deaths per 100 000 live births is incredibly high at 408 per 100 000 live births for the country. Abortion has been legalized in India for the past three decades. However, the share of unsafe abortion as a cause of maternal mortality continues to be alarming. The objective of the present study is to identify the magnitude of problem of unsafe abortion in India. METHODS: Emergency gynecologic admissions to a tertiary care center in North India over a 15-year period (1988-2002) were reviewed to evaluate the demographic and clinical profile of patients admitted as a result of unsafe abortion. The records were analyzed with regard to the age group, parity and marital status of the abortion seekers, the indication of abortion, the methods used, qualification of abortion providers, complications and fatality rate. RESULTS: The majority of women who were admitted with diagnosis of unsafe abortion were in the third decade of their lives. They were married, multiparous women living with their spouses. Sixty percent of the women had approached unqualified abortion providers who used primitive methods of pregnancy termination. All the women were admitted with serious complications of unsafe abortions and one-fourth of them succumbed to the complications. CONCLUSION: Unsafe abortion constitutes a major threat to the health and lives of women. This study highlights the need to focus more directly on the needs and preferences of women who seek abortion as well as on the accessibility of contraceptives and skills of the providers of abortion services, in order to improve the quality of abortion care.     

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.     

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.     

Health consequences of unsafe abortions

Maternal morbidity and mortality due to complications of unsafe abortion constitute a major public health concern in many countries. It is estimated that of the approximately 150,000 unwanted pregnancies that are terminated every day by induced abortion, 1/3 are performed under unsafe conditions, resulting in some 500 deaths every day. In many developing countries a substantial proportion of the limited national reproductive health care resources are spent on the management of abortion-related problems. To evaluate further the public health consequences of unsafe abortions, the Programme is supporting hospital-based studies of complications of abortion and their cost to the health care system in countries where safe abortion is not readily available. The studies employ a core protocol adapted to local conditions. Bangladesh, Chile, Ethiopia, and Thailand have completed such research, and similar studies are currently under way in 4 more countries--Benin, Brazil, Senegal, and Uganda. In Bangladesh, 1301 cases of abortion-related diagnoses admitted to hospital were included in the study. Some 46% were judged to have certainly had an induced abortion and another 16% were judged as possible cases of induced abortion. While no deaths occurred in women with spontaneous abortions, 18 of those who had had an induced abortion died. More hospital resources in terms of duration of stay, antibiotics, and blood were spent on cases of induced abortion compared to cases of spontaneous abortion. The study also found that on average abortion cases occupied hospital beds for a much longer duration compared to other obstetric cases.     

Unsafe abortion differentials in 2008 by age and developing country region: high burden among young women

Each year, nearly 22 million women worldwide have an unsafe abortion, almost all of which occur in developing countries. This paper estimates the incidence and rates of unsafe abortion by five-year age groups among women aged 15-44 years in developing country regions in 2008. Forty-one per cent of unsafe abortions in developing regions are among young women aged 15-24 years, 15% among those aged 15-19 years and 26% among those aged 20-24 years. Among the 3.2 million unsafe abortions in young women 15-19 years old, almost 50% are in the Africa region. 22% of all unsafe abortions in Africa compared to 11% of those in Asia (excluding Eastern Asia) and 16% of those in Latin America and the Caribbean are among adolescents aged 15-19 years. The number of adolescent women globally is approaching 300 million. Adolescents suffer the most from the negative consequences of unsafe abortion. Efforts are urgently needed to provide contraceptive information and services to adolescents, who have a high unmet need for family planning, and to women of all ages, with interventions tailored by age group. Efforts to make abortion safe in developing countries are also urgently needed.     

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.     

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.     

Reconceptualizing safe abortion and abortion services in the age of abortion pills: A discussion paper

At the conference “Developing an Advocacy Agenda for Abortion in the 21st Century and Making Change Happen” held on 5–7 September 2018, Lisbon, Portugal, organized by the International Campaign for Women's Right to Safe Abortion, it was argued that abortion services not only need to be treated as a bona fide form of health care but also completely reconceptualized, particularly because of the influence of medical abortion pills. It emerged, however, that there is no consensus on how this reconceptualization should be configured. Indeed, substantial differences arose, or so it appeared, complicated not only by different exigencies in national settings but also reflecting differing perspectives, specifically, those held primarily by health professionals compared to those held by advocates who felt they spoke for women needing abortions. In the course of these discussions, questions emerged on how much women should be able to do on their own, whether and why services were necessary in every case, where services should be located, what they should offer, who should provide them, and who should be in charge of the process.The biggest discussion was over the extent to which women can safely self-manage use of medical abortion pills for abortion in both the first and second trimester, and to what extent health professional control should be relinquished. Regardless of these arguments, however, since 1988 with the discovery in Brazil that misoprostol is an abortifacient, over-the-counter access to medical abortion (MA) pills began to put self-management of abortion on the map. Today, self-management is happening in almost every country, and we have no idea how many abortions are taking place anymore. Moreover, because of the work of safe abortion information hotlines, there is a growing body of evidence that self-management of abortion by women is safe – or at least far less unsafe than what prevailed in the past.Looking beyond the abortion rights movement, the crux of the issue is whether the state should continue to control abortion, with power over individual decisions delegated to the medical profession – or whether, as has been happening at a snail's pace for the last half century, and as with contraception and emergency contraception too – control can and should be more and more in women's hands.This paper examines these perspectives and attempts to describe what a consensus might look like. It concludes that convincing governments and conservative health professionals to accept a large dose of self-management will not be easy.     

Safe abortion: a right for refugees?

Thanks to initiatives since 1994, most reproductive health programmes for refugee women now include family planning and safe delivery care. Emergency contraception and post-abortion care for complications of unsafe abortion are recommended, but provision of these services has lagged behind, while services for women who wish to terminate an unwanted pregnancy are almost non-existent. Given conditions in refugee settings, including high levels of sexual violence, unwanted pregnancies are of particular concern. Yet the extent of need for abortion services among refugee women remains undocumented. UNFPA estimates that 25-50% of maternal deaths in refugee settings are due to complications of unsafe abortion. Barriers to providing abortion services may include internal and external political pressure, legal restrictions, or the religious affiliation of service providers. Women too may be pressured to continue pregnancies and are often unable to express their needs or assert their rights. Abortion advocacy efforts should highlight the specific needs of refugee women and encourage provision of services where abortion is legally indicated, especially in cases of rape or incest, and risk to a woman's physical and mental health. Implementation of existing guidelines on reducing the occurrence and consequences of sexual violence in refugee settings is also important. Including refugee women in international campaigns for expanded access to safe abortion is critical in addressing the specific needs of this population.     

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.     

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.