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Division of
Reproductive Health
(Technical Support)

World Health
Organization

CH-1211 GENEVA 27
SWITZERLAND

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En français

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Address Unsafe Abortion*
(WHD 98.10)

Each year, approximately 20 million unsafe abortions take place around the world, resulting in some 80,000 maternal deaths, and hundreds of thousands of disabilities.1 The vast majority of these deaths take place in developing countries.1 Unsafe abortion accounts for at least 13% of global maternal mortality ­ one in eight maternal deaths ­ and in some countries is the most common cause of maternal mortality and morbidity.1 Unsafe abortion is, however, one of the most easily preventable and treatable causes of maternal mortality and morbidity.

At the International Conference on Population and Development (ICPD) in Cairo in 1994, governments recognised unsafe abortion as a major public health issue and called for:

  • Prompt, high quality and humane medical services to treat the complications of unsafe abortion;
  • Compassionate postabortion counselling and family planning services to promote reproductive health, reduce the need for abortion and prevent repeat unsafe abortions and;
  • Safe induced abortion services where they are not against the law.2

* The World Health Organization acknowledges that data on unsafe abortion are scarce and subject to substantial error due to methodological constraints inherent in abortion-related research.

 

Unsafe Abortion: A Global Problem

Mortality: Millions of women around the world risk their lives and health to end an unwanted pregnancy. Every day, 55,000 unsafe abortions take place ­ 95% of them in developing countries1 ­ and lead to the deaths of more than 200 women daily.1 Globally, one unsafe abortion takes place for every seven births.1

Deaths from unsafe abortion account for a significant percentage of all maternal deaths, although accurate data are difficult to obtain. WHO estimates that globally, one maternal death in eight is due to abortion-related complications. In some settings a quarter or more of all maternal deaths are abortion-related.3

Many women are afraid to seek treatment for abortion-related complications, leading to countless ­ and uncounted ­ deaths outside of hospitals.4

Morbidity: Between 10 and 50% of all women who undergo unsafe abortions need medical care for complications. The most frequent complications are incomplete abortion, sepsis, haemorrhage and intra-abdominal injury, such as puncturing or tearing of the uterus.1

Long-term health problems caused by unsafe abortion include: chronic pelvic pain, pelvic inflammatory disease, tubal blockage and secondary infertility. Other possible consequences of unsafe abortion are ectopic pregnancy and an increased risk of spontaneous abortion or premature delivery in subsequent pregnancies.1 Such problems can limit women's productivity inside and outside the home, constrain their ability to care for children and adversely affect their sexual and reproductive lives.5

 

Unsafe Abortion: Regional estimates of mortality and risk of death1
Region No. of maternal deaths due to unsafe abortion Risk of dying after unsafe abortion % of maternal deaths due to unsafe abortion
Africa 33,000 1 in 150 13%
Asia* 37,500 1 in 250 12%
LAC ** 4,600 1 in 900 21%
Europe 500 1 in 1900 17%

* Japan, Australia and New Zealand excluded
** Latin America and Caribbean

 

Impact on the public health system: Treatment of abortion-related complications often requires several days of hospitalisation and staff time, as well as blood transfusions, antibiotics, pain control medicines and other drugs. Providing this care depletes funds and medical supplies needed for other types of treatment.1 As much as 50% of hospital budgets in some developing countries are used to treat complications of unsafe abortion.6, 7

A recent study in Tanzania found that 34% to 57% of all admissions to the gynaecological ward of a hospital in Dar es Salaam were women suffering from complications of abortion. It cost the hospital $7.50 per day to treat each woman. The national health budget allocated only $1 per person per year for health care.8

 

Which Women Seek Abortions and Why?

Most women seeking abortion are married or live in stable unions and already have several children; they seek abortions to limit the size of their family or space births, rather than to delay first birth.1

Women may find themselves with an unwanted pregnancy for many reasons. Non-use of contraception accounts for the majority of unwanted pregnancies. In addition, between 8 and 30 million pregnancies each year result from contraceptive failure ­ either inconsistent or incorrect use of family planning methods or method-related failure.9 Other factors women cite as reasons for an unwanted pregnancy include rape; lack of control over contraception; young age or single marital status; too many children; abandonment or an unstable relationship; mental or physical health problems; severe malformation of the fetus and financial constraints.10, 11, 12

Unsafe abortion is a public health problem at all ages but particularly among young women, who often have poor access to family planning information and services, and who are less likely than older women to have the social contacts and financial means to obtain a safe abortion.5 Also, young women are more likely to delay seeking help and hence seek terminations at more advanced stages of gestation, such as in the second trimester where morbidity and mortality are higher. In many African countries, up to 70% of all women hospitalised for abortion complications are younger than 20.13  

 

Prevalence of Modern Contraceptive Use14
Prevalence of Modern Contraceptice Use

 

Family Planning: Out of Reach

Despite the fact that family planning services are more effective and available than ever, estimates suggest that at least 350 million couples worldwide lack access to information about contraceptives and a range of modern family planning methods.14

Worldwide, between 120 to 150 million married women who want to limit or space future pregnancies are not using a contraceptive method and have an unmet need for family planning information and services. Between 12 and 15 million unmarried women also lack access to services that will enable them to achieve their reproductive intentions.14

Many women leave hospitals after treatment for complications of unsafe abortion without any counselling on how to prevent future pregnancies, and without a contraceptive method.4 In Zambia, for example, 78% of women treated for abortion complications indicated they would like to receive information about family planning, and 44% indicated they would have liked to receive a method. However, family planning was discussed with only 33% of the women, and none was offered a method to take home.11

 

Abortion-related deaths: numbers, and expressed as a percentage of all maternal deaths by region (around 1995)
Abortion-related deaths
* Japan, Australia and New Zealand are included in the total for more developed regions.

 

Legislation and Policies

National policies and legislation on abortion vary widely. In 98% of the world's countries danger to the woman's life is recognised as a legal basis for terminating a pregnancy. In 62% of countries some provision is made for preserving the woman's physical health as a basis for legal abortion, although definitions of the risk to health are diverse.15 Only in a few countries is abortion illegal in all circumstances.16

The evidence shows that restrictive legislation is associated with higher rates of unsafe abortion and correspondingly high mortality. In Romania, for example, abortion-related deaths increased sharply when the law became very restrictive in 1966 and fell after 1990 with a return to the less restrictive legislation.17

Contrary to common belief, legalisation of abortion does not necessarily increase abortion rates. The Netherlands, for example, has a non-restrictive abortion law, widely accessible contraceptives and free abortion services, and the lowest abortion rate in the world ­ 5.5 abortions per 1,000 women of reproductive age per year.16 Barbados, Canada, Tunisia and Turkey have all changed abortion laws to allow for greater access to legal abortion without increasing abortion rates.16

In order to reduce maternal morbidity and mortality from unsafe abortion, legislation to improve access to abortion services must be accompanied by changes in the health service structure. These should include the development of service delivery standards and, as appropriate, restructuring of the health system to ensure that high quality, safe services are available at the lowest levels compatible with good quality care. Staff must be trained to provide services, and supplies of necessary equipment and drugs must be available.20

 

Effects of the introduction in Romania in November 1966 of an anti-abortion law, and legalisation of abortion in December 1989
Effects of an anti-abortion law in Romania

 

Inadequate Health Services

In many developing countries, safe abortion services are not available to the full extent permitted by law. Many health workers, including doctors and nurses, lack vital information about its legal status or do not know how to perform abortions. Many women who would qualify for safe and legal abortion services are turned away due to providers' lack of knowledge about the exact implications of the law, or due to providers' ambiguous attitudes toward abortion, particularly vis-à-vis young people, unmarried women and other marginalised groups.4, 18, 19

When women experience complications due to unsafe abortion, appropriate medical care is often unavailable or inaccessible. Lack of protocols for postabortion care, misdiagnosis, punitive attitudes on the part of health care providers, and case overload result in life-threatening and costly delays for women seeking treatment from the health system.5

 

What Can Be Done

In order to reduce the current heavy toll of abortion-related maternal death and morbidity, governments, international agencies, women's groups and non-governmental organisations (NGOs) must take steps to ensure universal access to family planning; increase the availability of safe abortion services to the extent allowed by law; improve the quality and accessibility of postabortion care; educate their communities about reproductive health and unsafe abortion; and work for changes in policies to safeguard women's reproductive health.

 

Contraceptive Services and Information

High priority should be given to the prevention of unwanted pregnancy through comprehensive client-oriented reproductive health services. Non-judgmental attitudes, confidential counselling and quality family planning information and services should be universally accessible to all women, including emergency contraception where feasible and appropriate. Special attention should be given to the needs of young people, marginalised women, and those living in conflict situations and at risk of sexual abuse, rape and violence (see summary sheet: "Prevent Unwanted Pregnancy").

 

Quality of Care

In countries where abortion is legal:

  • Services should be safe and available to the full extent allowed by law, particularly in rural and impoverished areas.
  • Service providers must be carefully trained to offer high quality services and compassionate counselling. Providers must be well-informed about the legal status of abortion and protocols for providing services so that women eligible can access them quickly and without unnecessary delays or bureaucratic procedures.
  • Available services should be publicised within the community and links should be strengthened with women's groups, health centres and other related organisations to ensure that women who need services are informed about where and when to seek care.20

At the Hospital Jabaquara in São Paulo, Brazil, safe, legal abortion services were introduced for victims of rape, incest and when the woman's life is in danger. Protocols for routine treatment and counselling include: approval for the procedure; provision of emergency contraception when appropriate; evaluation by a social worker or psychologist; medical examination; pregnancy termination; follow-up reproductive health services, such as STD screening and treatment; and contraception.21

Appropriate technologies must be available both for the management of complications as well as for elective abortion when it is not against the law.22 New technologies, such as non-surgical abortion, should be made available, where appropriate and feasible.

 

Postabortion Care

Whatever the legal status of abortion, high-quality services for treating and managing complications of abortion should be accessible to all women.23

Key elements of postabortion care include: emergency treatment of abortion complications; family planning counselling and services; and links to comprehensive reproductive health services.24

To prevent abortion-related mortality, emergency postabortion care must be available 24 hours a day, since many women with serious complications require immediate care.24, 25 Every facility should have trained and authorised staff, appropriate equipment, explicit protocols for treatment procedures, a coordination mechanism between relevant units/departments and effective referral networks.25

All women who have had an induced abortion should be offered accurate information on family planning, sensitive counselling, a range of contraceptive methods and referral for ongoing care. However, postabortion care should never be contingent upon acceptance of contraception or of a particular method.26

In Ghana, midwives from community-based health centres and
private maternity homes were trained to treat cases of incomplete abortion and to counsel women on postabortion family planning
methods.27

In Nigeria, doctors and midwives from the Christian Health Association of Nigeria (CHAN), have been trained to provide postabortion care, as well as other reproductive health services, including screening and treatment for STDs.28

 

Community Education

Education is critical for reducing the public health problem of unsafe abortion. Health education messages should be based on the incidence and impact of unsafe abortion within communities, and be sensitive to people's existing beliefs, attitudes and practices. They should offer information on: the legal status of abortion; preventing unwanted pregnancy; avoiding unsafe abortion; and recognising and seeking appropriate treatment for abortion complications.29

In Bolivia, a government campaign, led by the President and Secretary of Health, was undertaken to raise awareness of a broad range of reproductive health issues, including deaths from unsafe abortion. An evaluation found that the campaign was highly successful, and that the unsafe abortion message had the highest level of recall of all the campaign's messages.30

 

Footnotes:

1. Abortion: A Tabulation of Available Information, 3rd edition. World Health Organization, Geneva, 1997, in press.

2. United Nations, Report of the International Conference on Population and Development. United Nations, New York, 1994.

3. World Health Organization. Abortion: A tabulation of available data on the frequency and motality of unsafe abortion, 3rd edition (in press).

4. K. Rogo, Prevention of Unsafe Abortion in Africa: A Case for a Community-based Approach. Proceedings: Abortion Matters, International Conference on Reducing the Need and Improving the Quality of Abortion Services, Stimezo Nederland, Utrecht, Netherlands, 1997.

5. Care for Postabortion Complications: Saving Women's Lives. Population Reports, Vol. 24, No. 2. September 1997.

6. M.A. Koblinksy, et al., eds., The Health of Women: A Global Perspective. Oxford: Westview Press, 1993.

7. WHO, Press Release 15 November 1994, WHO to discuss research results on adverse consequences of unsafe abortion in Latin America and the Caribbean, WHO, Geneva, 1994.

8. G.S. Mpangile, et al., Factors Associated with Induced Abortion in Public Hospitals in Dar es Salaam, Tanzania. Reproductive Health Matters, No. 2, 21-31, November 1993.

9. S.J. Segal and K.D. LaGuardia, Termination of pregnancy ­ a global view. Baillière's Clinical Obstetrics and Gynaecology, 4 (2) 235-247, 1990.

10. Expanding Access to Safe Abortion: Key Policy Issues. Population Action International, Washington, DC, September 1993.

11. S.N. Kinoti, et al., Monograph on Complications of Unsafe Abortion in Africa. Commonwealth Regional Health Community Secretariat for East, Central and Southern Africa, Arusha, Tanzania, 1995.

12. Clandestine Abortion: A Latin American Reality. The Alan Guttmacher Institute, New York, 1994.

13. The Health of Young People. A Challenge and a Promise. World Health Organization, Geneva, 1993.

14. The State of World Population 1997. UNFPA, New York, 1997.

15. Abortion Policies: A Global Review, Volume 1. Afghanistan to France (1992); Volume 2. Gabon to Norway (1993); Volume 3. Oman to Zimbabwe (1995), United Nations, New York.

16. S. Henshaw, Abortion Laws and Practice Worldwide, in Proceedings: Abortion Matters, International Conference on Reducing the Need and Improving the Quality of Abortion Services, Stimezo Nederland, Utrecht, Netherlands, 1997.

17. Preventing maternal deaths. World Health Organization, Geneva, 1989.

18. Facts in Brief: Abortion in the United States. Abortion Factbook 1992 Edition, The Alan Guttmacher Institute, New York, 1992.

19. Unsafe Abortion and Postabortion Family Planning in Africa: the Mauritius Conference. International Planned Parenthood Federation, Nairobi, 1994.

20. Abortion Laws into Action: Implementing Legal Reform. Initiatives in Reproductive Health Policy, Vol. 2, No. 1. January 1997, Ipas, Carrboro, NC 1997.

21. I.G. Pereira and C.N. daMota, Manual para o estabelecimento de um serviço de atendimento para aborto previsto por lei, Ipas, Carrboro, NC, 1996.

22. H. McKay and B. Hartley, How Can You Combat Unsafe Abortion?: Practical Approaches in Action. Planned Parenthood Challenges, 1993/1. International Planned Parenthood, 1993.

23. United Nations, Platform for Action, The Fourth World Conference on Women. New York, 1995.

24. Postabortion Care: A Reference Manual for Improving Quality of Care. Postabortion Care Consortium, Baltimore,1995.

25. Complications of Abortion: Technical and Managerial Guidelines for Prevention and Treatment. WHO, Geneva, 1995.

26. K.E. McLaurin, et al., Meeting Women's Needs for Post-Abortion Family Planning: Report of a Bellagio Technical Working Group, International Journal of Gynaecology & Obstetrics, Vol. 45 (supplement), 1994.

27. K. Otsea, et al., Midwives Deliver Postabortion Care Services in Ghana. Dialogue, Vol. 1, No. 1, June 1997. Ipas, Carrboro, NC, 1997.

28. Promoting Improved Women's Reproductive Health in Nigeria. Africa Reports, Ipas, Carrboro, NC, 1995.

29. Prevention and Management of Unsafe Abortion: A Guide for Action (unpublished draft). Family Care International, New York, 1997.

30. Reproductive Health is in Your Hands: Impact of the Bolivia National Reproductive Health Campaign. IEC Report No. 4, JHPIEGO, February 1996.

 

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