Preventing unsafe abortion
- Between 2010–2014:
- On average, 56 million induced (safe and unsafe) abortions occurred worldwide each year.
- There were 35 induced abortions per 1000 women aged between 15–44 years.
- 25% of all pregnancies ended in an induced abortion.
- The rate of abortions was higher in developing regions than in developed regions.
- Around 25 million unsafe abortions were estimated to have taken place worldwide each year, almost all in developing countries (1).
- Among these, 8 million were carried out in the least- safe or dangerous conditions
- Over half of all estimated unsafe abortions globally were in Asia
- 3 out of 4 abortions that occurred in Africa and Latin America were unsafe
- The risk of dying from an unsafe abortion was the highest in Africa
- Each year between 4.7% – 13.2% of maternal deaths can be attributed to unsafe abortion (2).
- Around 7 million women are admitted to hospitals every year in developing countries, as a result of unsafe abortion (3).
- The annual cost of treating major complications from unsafe abortion is estimated at $553 million (4).
- Safe abortion must be provided or supported by a trained person using WHO recommended methods appropriate for the pregnancy duration.
- Almost every abortion death and disability could be prevented through sexuality education, use of effective contraception, provision of safe, legal induced abortion, and timely care for complications.
Abortions are safe if they are done with a method recommended by WHO that is appropriate to the pregnancy duration and if the person providing or supporting the abortion is trained. Such abortions can be done using tablets (medical abortion) or a simple outpatient procedure.
Unsafe abortion occurs when a pregnancy is terminated either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. The persons, skills and medical standards considered safe in the provision of induced abortions are different for medical abortion (which is performed with drugs alone), and surgical abortion (which is performed with a manual or electric aspirator). Skills and medical standards required for safe abortion also vary depending upon the duration of the pregnancy and evolving scientific advances.
- They are less safe, when done using outdated methods like sharp curettage even if the provider is trained or if women using tablets do not have access to proper information or to a trained person if they need help.
- Abortions are dangerous or least safe when they involve ingestion of caustic substances or untrained persons use dangerous methods such as insertion of foreign bodies, or use of traditional concoctions.
Women, including adolescents, with unwanted pregnancies often resort to unsafe abortion when they cannot access safe abortion. Barriers to accessing safe abortion include:
- restrictive laws
- poor availability of services
- high cost
- conscientious objection of health-care providers and
- unnecessary requirements, such as:
- mandatory waiting periods
- mandatory counselling
- provision of misleading information
- third-party authorization
- medically unnecessary tests.
Scope of the problem
Based on data from 2010 -2014 there are approximately 25 million unsafe abortions annually. Of these one third or approximately 8 million were performed under the least safe conditions by untrained persons using dangerous and invasive methods. Unsafe abortions lead to an estimated 7 million complications (3).
In developed regions, it is estimated that 30 women die for every 100 000 unsafe abortions. That number rises to 220 deaths per 100 000 unsafe abortions in developing regions and 520 deaths per 100 000 unsafe abortions in sub-Saharan Africa.
Mortality from unsafe abortion disproportionately affects women in Africa. While the continent accounts for 29% of all unsafe abortions, it sees 62% of unsafe abortion-related deaths (1).
Who is at risk?
Any woman with an unwanted pregnancy who cannot access safe abortion is at risk of unsafe abortion. Women living in low-income countries and poor women are more likely to have an unsafe abortion. Deaths and injuries are higher when unsafe abortion is performed later in pregnancy. The rate of unsafe abortions is higher where access to effective contraception and safe abortion is limited or unavailable.
Complications of unsafe abortion requiring emergency care
Following unsafe abortion, women may experience a range of harms that affect their quality of life and well-being, with some women experiencing life-threatening complications. The major life-threatening complications resulting from the least safe abortions are haemorrhage, infection, and injury to the genital tract and internal organs. Unsafe abortions when performed under least safe conditions can lead to complications such as:
- incomplete abortion (failure to remove or expel all of the pregnancy tissue from the uterus)
- haemorrhage (heavy bleeding)
- uterine perforation (caused when the uterus is pierced by a sharp object)
- damage to the genital tract and internal organs by inserting dangerous objects such as sticks, knitting needles, or broken glass into the vagina or anus.
Signs and symptoms
An accurate initial assessment is essential to ensure appropriate treatment and prompt referral for complications of unsafe abortion. The critical signs and symptoms of complications that require immediate attention include:
- abnormal vaginal bleeding
- abdominal pain
- shock (collapse of the circulatory system).
Complications of unsafe abortion can be difficult to diagnose. For example, a woman with an extra-uterine or ectopic pregnancy (abnormal development of a fertilized egg outside of the uterus) may have symptoms similar to those of incomplete abortion. It is essential, therefore, for health-care personnel to be prepared to make referrals and arrange transport to a facility where a definitive diagnosis can be made and appropriate care can be delivered quickly.
Treatment and care
Complications arising from unsafe abortions and their treatments include:
- Haemorrhage: timely treatment of heavy blood loss is critical, as delays can be fatal.
- Infection: treatment with antibiotics along with evacuation of any remaining pregnancy tissue from the uterus as soon as possible.
- Injury to the genital tract and/or internal organs: if this is suspected, early referral to an appropriate level of health care is essential.
Access to treatment for abortion complications
Health-care providers are obligated to provide life-saving medical care to any woman who suffers abortion-related complications, including treatment of complications from unsafe abortion, regardless of the legal grounds for abortion. However, in some cases, treatment of abortion complications is administered only on the condition that the woman provides information about the person(s) who performed the illegal abortion.
The practice of extracting confessions from women seeking emergency medical care as a result of illegal abortion puts women's lives at risk. The legal requirement for doctors and other health-care personnel to report cases of women who have undergone abortion, delays care and increases the risks to women’s health and lives. UN human rights standards call on countries to provide immediate and unconditional treatment to anyone seeking emergency medical care (6) .
Prevention and control
Unsafe abortion can be prevented through:
- comprehensive sexuality education;
- prevention of unintended pregnancy through use of effective contraception, including emergency contraception; and
- provision of safe, legal abortion.
In addition, deaths and disability from unsafe abortion can be reduced through the timely provision of emergency treatment of complications.
In addition to the deaths and disabilities caused by unsafe abortion, there are major social and financial costs to women, families, communities, and health systems. In 2006, it was estimated that $553 million was spent treating serious consequences of unsafe abortion (4). An additional $375 million would be required to fully meet the unmet need for treatment of complications from unsafe abortion (4).
WHO provides global technical and policy guidance on the use of contraception to prevent unintended pregnancy, safe abortion, and treatment of complications from unsafe abortion. In 2012, WHO published updated technical and policy guidance on safe abortion. WHO recommendations for safe abortion can be found in the following publications:
- Safe abortion: technical and policy guidance for health systems
- Clinical practice handbook for safe abortion
- Health worker roles in providing safe abortion care and post-abortion contraception (2015)
An interactive online database containing comprehensive information on the abortion laws, policies, health standards and guidelines for all countries is available at http://www.srhr.org/abortion-policies.
Technical support to countries
Upon request, WHO provides technical support to countries to adapt sexual and reproductive health guidelines to specific contexts and strengthen national policies and programmes related to contraception and safe abortion care.
WHO is a cosponsor of the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, which carries out research on clinical care as well as implementation research on community and health systems approaches to preventing unsafe abortion. It also monitors the global burden of unsafe abortion and its consequences.
(1) Ganatra B, Gerdts C, Rossier C, Johnson Jr B R, Tuncalp Ö, Assifi A, Sedgh G, Singh S, Bankole A, Popinchalk A, Bearak J, Kang Z, Alkema L. Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model. The Lancet. 2017 Sep
(2) Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, Gülmezoglu AM, Temmerman M, Alkema L. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014 Jun; 2(6):e323-33.
(3) Singh S, Maddow-Zimet I. Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012: a review of evidence from 26 countries. BJOG 2015; published online Aug 19. DOI:10.1111/1471-0528.13552.
(4) Vlassoff et al. Economic impact of unsafe abortion-related morbidity and mortality: evidence and estimation challenges. Brighton, Institute of Development Studies, 2008 (IDS Research Reports 59).
(5) L Haddad. Unsafe Abortion: Unnecessary Maternal Mortality. Rev Obstet Gynecol. 2009 Spring; 2(2): 122–126.
(6) Human Rights Committee; Committee Against Torture; Committee on the Elimination of Discrimination Against Women.