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.     

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.     

New estimates and trends regarding unsafe abortion mortality

Background

The 1990–2008 estimates for the maternal mortality associated with unsafe abortion require a re-examination.

Objective

To provide the latest estimates of the mortality associated with unsafe abortion and to examine trends within the framework of new maternal mortality estimates.

Search strategy

Extensive search of databases and websites for country- and region-specific data on unsafe abortion.

Selection criteria

Reports, papers, and websites with data on unsafe abortion incidence and mortality.

Data collection and analysis

Earlier published estimates for the unsafe-abortion-related mortality were recalculated by country for 1990, 1997, 2000, and 2003 to harmonize with the new maternal mortality estimates. The resulting estimates were aggregated to give subregional, regional, and global figures, including those recently estimated for 2008.

Main results

In 2008, unsafe abortions accounted for an estimated 47 000 maternal deaths, down from 69 000 in 1990. Globally, the unsafe-abortion mortality ratio has declined from 50 in 1990 to 30 in 2008. The overall burden of unsafe abortion mortality continues to be the highest in Africa.

Conclusions

Important gains have been made in reducing maternal deaths attributable to unsafe abortion. However, 1 in 8 maternal deaths globally and 1 in 5 maternal deaths in Eastern Africa continue to be attributable to unsafe abortion. Averting these preventable deaths can contribute to achieving Millennium Development Goal number 5 of improving maternal health.     

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.     

Global perspective of legal abortion – Trends analysis and accessibility

There are significant variations in the legalisation, restrictions and legal abortion rates worldwide. This undoubtedly influences the provision and accessibility to abortion services. Although there have been changes to the laws in several countries over the last decade, this has not yet been translated into practice in the provision of safe abortion in these countries. In countries where abortions are permitted without restriction; the majority of abortions are carried out by trained practitioners in approved facilities. In contrast, in countries where restrictions are imposed, the majority of abortions performed are considered to be unsafe and therefore associated with significant morbidity and mortality. This article discusses the most recent data available regarding worldwide legal abortion rates, trends over the last ten years and issues related to specific regions which may influence the provision of safe abortion services in the future.     

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.     

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.     

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.     

Perceptions,interpretations and implications of abortions: A qualitative enquiry among the legal community of Pakistan

ABSTRACT

Background The number of unsafe abortions is increasing across South Asia, also in Pakistan, where abortion is only permitted under special circumstances. The law on abortion is vaguely interpreted by the legal community.

Methods Using Grounded Theory, 33 in-depth interviews of representatives of the legal profession and law enforcement agencies were conducted in 2010.

Results Abortion is perceived as forbidden by both law and religion, and a punishable crime. Respondents believed that sentences are highly dependent on the social status of the woman who had the abortion. A few consider the current law as relevant and sufficient whereas the majority would support amendments. A number of them agreed that the high abortion rate reflects the denial of women's rights, social injustice, and a failure of public health intervention.

Conclusion To facilitate access of women to abortion and related care, the knowledge of the existing law among legal professionals must improve. The implications of abortion for maternal health and its repercussions on a community governed by the Islamic dogmas must be publicised. The legal community could have an instrumental role in bringing about attitudinal changes vis-à-vis abortions in the society.     

Systematic Review of the Effectiveness,Safety, and Acceptability of Mifepristone and Misoprostol for Medical Abortion in Low- and Middle-Income Countries

ObjectiveAbortion-related complications remain one of the leading causes of maternal morbidity and mortality worldwide. Nearly half of all abortions are unsafe, and the vast majority of these occur in low- and middle-income countries. The use of mifepristone with misoprostol for medical abortion has been proposed and implemented to improve abortion safety.Data SourcesA systematic review of the literature was conducted in PubMed, Embase, Cochrane, and CINAHL.Study SelectionCriteria for study inclusion were first-trimester abortion, use of mifepristone with misoprostol, and low- or middle-income country status as designated by the World Health Organization.Data ExtractionResults for effectiveness, safety, acceptability, and qualitative information were assessed.Data SynthesisThe literature search resulted in 181 eligible articles, 52 of which met our criteria for inclusion. A total of 34 publications reported effectiveness data on 25 385 medical abortions. The average effectiveness rate with mifepristone 200 mg and misoprostol 800 µg was 95% up to 63 days gestation. A sensitivity analysis was performed to assume that all women lost to follow-up failed treatment, and the recalculated effectiveness rate remained high at 93%. The average continuing pregnancy rate was 0.6%. A total of 22 publications reported safety and acceptability data on 17 381 medical abortions. Only 0.8% abortions required presentation to hospital, and 87% of patients found the side effects of treatment acceptable. Overall, 95% of women were satisfied with their medical abortion, 94% would choose the method again, and 94% would recommend this method to a friend. A total of 16 publications reported qualitative results and the majority supported positive patient experiences with medical abortion.ConclusionsMifepristone and misoprostol is highly effective, safe, and acceptable to women in low- and middle-income countries, making it a feasible option for reducing maternal morbidity and mortality worldwide.     

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.     

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.     

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.     

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.     

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.     

Maternal Mortality at the Women''s and Children''s Hospital, South Okkalapa (1978–1982)

The maternal deaths between the years 1978 and 1982 were studied. There were 22,468 maternities and 10,623 abortion patients treated at the hospital. There were 44 maternal deaths; 22 due to abortion and 22 due to other causes. The maternal mortality rate including abortions was 1.33 per 1,000 maternities and that excluding abortions 0.98 per 1,000. The abortion was 2.0 per 1,000 abortions treated at the hospital. To reduce maternal mortality, ways and means should be found to reduce the abortion deaths, most of which were avoidable.     

Breaking the cycle of unsafe abortion in Africa

Globally, nearly half of all maternal deaths from unsafe abortion occur in Africa. Abortion-related deaths and injuries are especially tragic, because when properly performed, abortion is one of the safest of all medical procedures. Factors contributing to this neglected public health crisis include inadequate health care resources and infrastructure, restrictive laws and policies, stigma, and women's lack of empowerment. Actions needed include making high quality abortion care more available and accessible, especially at the primary care level and to the full extent permitted by law. Others include removing medically unnecessary policy and legal restrictions on abortion; and better informing health care professionals, women and communities about the impact of unsafe abortion and the circumstances under which abortion can be legally obtained.     

Preventing unsafe abortion in Western Kenya: An innovative approach through private physicians

Complications of unsafe abortion remain one of the major causes of maternal morbidity and mortality in Africa - up to 55 per cent of deaths and chronic and debilitating sequelae.¹I Where there are restrictive abortion laws and/or limited access to trained service providers, women are forced to resort to clandestine, unsafe methods. In such places, there is often a large body of private physicians who are assumed to be either aloof or mercenary with regard to post-abortion care; their potential contribution to reproductive health care remains under-utilised. This paper describes the firstyear's experiences of a project we launched in Western Kenya to form a network of private physicians and train them to provide comprehensive, affordable post-abortion care and family planning. Links between this network and primary health care workers and local women's groups are currently being made and will further enhance the potential for reducing the incidence of both unwanted pregnancies and dangerous abortions. Setting up and expanding such networks is an important practical and innovative approach to realising the goals of safe motherhood.     

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.     

Attitudes towards the legal context of unsafe abortion in Timor-Leste

The new Penal Code in 2009 was an opportunity for Timor-Leste to allow some legal grounds for abortion, which was highly restricted under Indonesian rule. Public debate was contentious before ratification of the new code, which allowed abortion to save a woman’s life and health. A month later, 13 amendments to the code were passed, highly restricting abortion again. This paper describes the socio-legal context of unsafe abortion in Timor-Leste, based on research in 2006–08 on national laws and policies and interviews with legal professionals, police, doctors and midwives, and community-based focus group discussions. Data on unsafe abortions in Timor-Leste are rarely recorded. A small number of cases of abortion and infanticide are reported but are rarely prosecuted, due to deficiencies in evidence and procedure. While there are voices supporting law reform, the Roman Catholic church heavily influences public policy and opinion. Professional views on when abortion should be legal varied, but in the community people believed that saving women’s lives was paramount and came before the law. The revised Penal Code is insufficient to reduce unsafe abortion and maternal mortality. Change will be slow, but access to safe abortion and modern contraception are crucial to women’s ability to participate fully as citizens in Timor-Leste.