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Safe Abortion: Technical and Policy Guidance for Health Systems. 2nd edition. Geneva: World Health Organization; 2012.
This publication is provided for historical reference only and the information may be out of date.
Summary
- Each year, 22 million unsafe abortions are estimated to take place. Nearly all unsafe abortions (98%) occur in developing countries. The total number of unsafe abortions has increased from about 20 million in 2003 to 22 million in 2008, although the global rate of unsafe abortion has remained unchanged since 2000.
- Approximately 47 000 pregnancy-related deaths are due to complications of unsafe abortion. In addition, 5 million women are estimated to suffer disability as a result of complications due to unsafe abortion.
- Impressive gains in contraceptive use have resulted in reducing the number of unintended pregnancies, but have not eliminated the need for access to safe abortion. An estimated 33 million contraceptive users worldwide are expected to experience accidental pregnancy annually while using contraception. Some of the accidental pregnancies are terminated by induced abortions, and some end up as unplanned births.
- Whether abortion is legally more restricted or available on request, a woman's likelihood of having an unintended pregnancy and seeking induced abortion is about the same. However, legal restrictions, together with other barriers, mean many women induce abortion themselves or seek abortion from unskilled providers. The legal status of abortion has no effect on a woman's need for an abortion, but it dramatically affects her access to safe abortion.
- Where legislation allows abortion under broad indications, the incidence of and complications from unsafe abortion are generally lower than where abortion is legally more restricted.
- In almost all countries, the law permits abortion to save the woman's life, and in the majority of countries abortion is allowed to preserve the physical and/or mental health of the woman. Therefore, safe abortion services, as provided by law, need to be available.
- Unsafe abortion and associated morbidity and mortality in women are avoidable. Safe abortion services therefore should be available and accessible for all women, to the full extent of the law.
1.1. Background
Induced abortion has been documented throughout recorded history (1). In earlier times, abortions were unsafe and exerted a heavy toll on women's lives. Advances in medical practice in general, and the advent of safe and effective technologies and skills to perform induced abortion in particular, could eliminate unsafe abortions and related deaths entirely, providing universal access to these services is available. Yet, an estimated 22 million abortions continue to be unsafe each year, resulting in the death of an estimated 47 000 women (2).
Unsafe abortion is defined by the World Health Organization (WHO) 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.
In nearly all developed countries (as classified by the United Nations Population Division) safe abortions are legally available upon request or under broad social and economic grounds, and services are generally accessible to most women. With the exception of a few countries, access to safe abortion in developing countries is limited to a restricted number of narrow conditions (3). In countries where abortion is legally highly restricted, unequal access to safe abortion may result. In such contexts, abortions that meet safety requirements can become the privilege of the rich, while poor women have little choice but to resort to unsafe providers, which may cause disability and death (4).
This chapter provides an overview of the health, demographic, legal and policy context of induced abortion with updated data since the publication of the document Safe abortion: technical and policy guidance for health systems by WHO in 2003 (5).
1.2. Public health and human rights
A consensus on the public health impact of unsafe abortion has existed for a long time. As early as 1967, the World Health Assembly identified unsafe abortion as a serious public health problem in many countries (6). WHO's Reproductive Health Strategy to accelerate progress towards the attainment of international development goals and targets, adopted by the World Health Assembly in 2004, noted:
“As a preventable cause of maternal mortality and morbidity, unsafe abortion must be dealt with as part of the Millennium Development Goal on improving maternal health and other international development goals and targets” (7).
The number of declarations and resolutions signed by countries over the past two decades (see for example, references 8–11) indicates a growing consensus that unsafe abortion is an important cause of maternal death that can, and should, be prevented through the promotion of sexuality education, family planning, safe abortion services to the full extent of the law, and post-abortion care in all cases. The consensus also exists that post-abortion care should always be provided, and that expanding access to modern contraception is critical to the prevention of unplanned pregnancy and unsafe abortion. Thus, the public health rationale for preventing unsafe abortion is clear and unambiguous.
Discussions that grew out of the 1968 International Conference on Human Rights in Tehran, Islamic Republic of Iran, culminated in the new concept of reproductive rights, which was subsequently defined and accepted at the 1994 International Conference on Population and Development (ICPD) in Cairo, Egypt (8). Eliminating unsafe abortion is one of the key components of the WHO Global reproductive health strategy (12). The strategy is grounded in international human rights treaties and global consensus declarations that call for the respect, protection and fulfilment of human rights, including the right of all persons to the highest attainable standard of health; the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so; the right of women to have control over, and decide freely and responsibly on, matters related to their sexuality, including sexual and reproductive health – free of coercion, discrimination and violence; the right of men and women to choose a spouse and to enter into marriage only with their free and full consent; the right of access to relevant health information; and the right of every person to enjoy the benefits of scientific progress and its applications (12). To realize these rights, and to save women's lives, programmatic, legal and policy aspects of the provision of safe abortion need to be adequately addressed, as elaborated further in the following chapters.
1.3. Pregnancies and abortions
Among the 208 million women estimated to become pregnant each year worldwide, 59% (or 123 million) experience a planned (or intended) pregnancy leading to a birth or miscarriage or a stillbirth (4). The remaining 41% (or 85 million) of pregnancies are unintended.
Because of increased contraceptive use, the pregnancy rate worldwide has fallen from 160 pregnancies per 1000 women aged 15–44 years in 1995 to 134 per 1000 women in 2008 (4). Rates of intended and unintended pregnancies have fallen from, respectively, 91 and 69 per 1000 women aged 15–44 years in 1995 to 79 and 55 per 1000 women aged 15–44 years in 2008. More significantly, the rate of induced abortion has declined from 35 per 1000 women aged 15–44 years in 1995 to 26 per 1000 women aged 15–44 years in 2008. This decline has been largely due to a fall in the rate of safe abortion, while the rate of unsafe abortion has remained relatively constant since 2000 at around 14 per 1000 women aged 15–44 years (13). The absolute number of unsafe abortions was estimated at about 20 million in 2003 and 22 million in 2008. The proportion of all abortions that are unsafe has increased from 44% in 1995 and 47% in 2003 to 49% in 2008 (13). Almost all unsafe abortions occur in developing countries, where maternal mortality rates are high and access to safe abortion is limited.
1.4. Health consequences of unsafe abortion
The health consequences of unsafe abortion depend on the facilities where abortion is performed; the skills of the abortion provider; the method of abortion used; the health of the woman; and the gestational age of her pregnancy. Unsafe abortion procedures may involve insertion of an object or substance (root, twig or catheter or traditional concoction) into the uterus; dilatation and curettage performed incorrectly by an unskilled provider; ingestion of harmful substances; and application of external force. In some settings, traditional practitioners vigorously pummel the woman's lower abdomen to disrupt the pregnancy, which can cause the uterus to rupture, killing the woman (14). The consequences of using certain medicines, such as the prostaglandin analogue misoprostol, in incorrect dosages for inducing abortion are mixed, though there is some evidence that even an incorrect dosage can still result in lowering the number of severe complications and maternal deaths (15–17).
Deaths and disability related to unsafe abortion are difficult to measure. Given that these deaths or complications occur following a clandestine or illegal procedure, stigma and fear of punishment deter reliable reporting of the incident. It is especially difficult to get reliable data on deaths from unsafe second-trimester abortions (18). Moreover, women may not relate their condition to a complication of an earlier abortion (19). Therefore, maternal deaths resulting from unsafe abortions are grossly underreported. Complications of unsafe abortion include haemorrhage, sepsis, peritonitis, and trauma to the cervix, vagina, uterus and abdominal organs (20). About 20–30% of unsafe abortions cause reproductive tract infections and 20–40% of these result in infection of the upper genital tract (21). One in four women who undergo unsafe abortion is likely to develop temporary or lifelong disability requiring medical care (22). For every woman seeking post-abortion care at a hospital, there are several who have had an unsafe abortion but who do not seek medical care, because they consider the complication as not serious, or because they may not have the required financial means, or because they fear abuse, ill-treatment or legal reprisal (23–30). Evidence shows that major physiological, financial and emotional costs are incurred by women who undergo unsafe abortion.
The burdens of unsafe abortion and of maternal deaths due to unsafe abortion are disproportionately higher for women in Africa than in any other developing region (31). For example, while Africa accounts for 27% of global births annually and for only 14% of the women aged 15–49 years in the world, its share of global unsafe abortions was 29% and, more seriously, 62% of all deaths related to unsafe abortion occurred in Africa in 2008 (see Figure 1.1). The risk of death due to unsafe abortion varies among developing regions. The case–fatality rate for unsafe abortion is 460 per 100 000 unsafe abortion procedures in Africa and 520 per 100 000 in sub-Saharan Africa, compared with 30 per 100 000 in Latin America and the Caribbean and 160 per 100 000 in Asia (2).
When performed by skilled providers using correct medical techniques and drugs, and under hygienic conditions, induced abortion is a very safe medical procedure. In the United States of America (USA), for example, the case–fatality rate is 0.7 per 100 000 legal abortions (32). Late second-trimester legal abortion has a case–fatality rate (33) that is much lower than the lowest rate of unsafe abortion procedures (see Figures 1.2 and 1.3).
1.5. Contraceptive use, accidental pregnancies and unmet need for family planning
The prevalence of contraception of any method was 63% globally in 2007 among women of reproductive age (15–49 years) who were married or in a cohabiting union (34). The use of a modern method was about seven percentage points lower, at 56%. Contraceptive prevalence rose globally and in all regions, though it remains low in Africa, at 28% for all methods and 22% for modern methods (see Figure 1.4). The prevalence is even lower in sub-Saharan Africa, where, in 2007, the use of any contraceptive method was 21%, while the use of modern methods was 15%. In contrast, contraceptive prevalence of any method was over 66% in Europe, North America, Asia, and Latin America and the Caribbean.
The use of modern contraception has resulted in a lowering of the incidence and prevalence of induced abortion even where abortion is available on request. The decline in abortion prevalence with the increase in the level of contraceptive prevalence has been examined by several authors (35, 36). Recent data from 12 countries in eastern Europe and central Asia, where induced abortion used to be the main method for regulating fertility, and from the USA, show that where the use of modern contraceptive methods is high, the incidence of induced abortion is low (37). Rates of induced abortion are the lowest in western Europe, where modern contraceptive use is high and abortion is generally legally available on request. Meeting the unmet need for family planning is, therefore, an effective intervention to reduce unintended pregnancy and induced abortion.
Contraception alone, however, cannot entirely eliminate women's need for access to safe abortion services. Contraception plays no role in cases of forced sexual intercourse, which can lead to an unintended pregnancy. Also, no method is 100% effective in preventing pregnancy. Using 2007 data on contraceptive prevalence (34) and the typical failure rates of contraceptive methods (51), it is estimated that approximately 33 million women worldwide annually may experience an accidental pregnancy while using a method of contraception (see Table 1.1). In the absence of safe abortion services, some may resort to unskilled providers and the others may end up having unwanted births. The implications of unwanted births are not well studied, but the effects can be harmful and long-lasting for women and for those who are born unwanted (38).
Unmet need for family planning, broadly defined as the number of women who want to avoid or postpone a pregnancy but are not using any method of contraception, continues to persist, despite having declined somewhat (39). Overall, 11% of women in developing countries report an unmet need for family planning. In sub-Saharan Africa and among the least developed countries, unmet need for family planning is reported by one in four women in the reproductive age group of 15–49 years (39). Women will continue to face unintended pregnancies as long as their family planning needs are not met.
Unlike unmet need for family planning, the lack of access to safe abortion care is less well documented, except for the stark reality of an estimated 22 million women undergoing unsafe abortion each year (2), with 47 000 of them dying from the complications. Even a “low-risk” unsafe abortion in a legally restricted context exposes women to an undue risk should an emergency develop in the process. In such cases, because of legal restrictions and stigma linked to having an abortion, women may be reluctant to seek timely medical care if post-abortion complications occur.
1.6. Regulatory and policy context
Where laws and policies allow abortion under broad indications, the incidence of, and mortality from, unsafe abortion are reduced to a minimum (2). Abortion is permitted for social or economic reasons in only 16% of developing countries as compared with 80% of developed countries (see Table 1.2). Three out of four induced abortions in developing countries (excluding the People's Republic of China) are carried out in unsafe conditions (13). In these countries, few women meet the legal conditions, or know their right, to receive the safe abortion services to which they are legally entitled. Also, providers may not be aware of the legal provisions or may be unwilling to provide legal abortion services. Furthermore, in some countries, laws are not applied (40).
Whether abortion is legally restricted or not, the likelihood that a woman will have an abortion for an unintended pregnancy is about the same (13). The legal restrictions lead many women to seek services in other countries, or from unskilled providers or under unhygienic conditions, exposing them to a significant risk of death or disability. The maternal mortality ratio per 100 000 live births due to unsafe abortion is generally higher in countries with major restrictions and lower in countries where abortion is available on request or under broad conditions (41, 42). The accumulated evidence shows that the removal of restrictions on abortion results in reduction of maternal mortality due to unsafe abortion and, thus, a reduction in the overall level of maternal mortality (43, 44, 45, 46).
In a small number of countries, where maternal mortality is low despite restrictive abortion laws, many women have access to safe or relatively safe abortion through seeking care from neighbouring countries, through provision of safe, but illegal abortion care domestically, or through self-use of misoprostol (47–49).
In addition to the legal restrictions, other barriers to safe abortion include inability to pay, lack of social support, delays in seeking health-care, providers' negative attitudes, and poor quality of services. Young women are especially vulnerable where effective contraceptive methods are available only to married women or where the incidence of non-consensual sexual intercourse is high. Nearly 14% of all unsafe abortions in developing countries are among women aged under 20 years. In Africa, young women below the age of 25 years account for nearly two thirds of all unsafe abortions in that region (50). A higher percentage of young women, compared with adult women, tend to have second-trimester abortions, which are more risky.
1.7. Economic costs of unsafe abortion
Safe abortion is cost saving. The cost to health systems of treating the complications of unsafe abortion is overwhelming, especially in poor countries. The overall average cost per case that governments incur is estimated (in 2006 US dollars) at US$ 114 for Africa and US$ 130 for Latin America (52). The economic costs of unsafe abortion to a country's health system, however, go beyond the direct costs of providing post-abortion services. A recent study (52) estimated an annual cost of US$ 23 million for treating minor complications from unsafe abortion at the primary health-care level; US$ 6 billion for treating post-abortion infertility; and US$ 200 million each year for the out-of-pocket expenses of individuals and households in sub-Saharan Africa for the treatment of post-abortion complications. In addition, US$ 930 million is the estimated annual expenditure by individuals and their societies for lost income from death or long-term disability due to chronic health consequences of unsafe abortion (52).
Unsafe abortion was estimated to cost the Mexico City health system US$ 2.6 million in 2005, before the legalization of abortion (53). With access to safe abortion, the system could potentially save US$ 1.7 million annually. A large amount of money can thus be conserved and redirected to meeting other urgent needs, including the provision of quality services using up-to-date standards and guidelines, trained providers and appropriate technologies, if unintended pregnancies are prevented by effective contraception, and safe abortion is accessible. Economic grounds further strengthen the public-health and human-rights rationale for the provision of safe abortion.
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