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Chapter 3: Previous page | 1,2,3,4,5,6

Not Every Pregnancy is Welcome

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Planning pregnancies before they even happen

Many women intend to get pregnant. Each year an estimated 123 million succeed. But a substantial additional number of women – around 87 million – become pregnant unintentionally. For some women and their partners this may be a pleasant surprise, but for others the pregnancy may be mistimed or simply unwanted ( 77 ). Of the estimated 211 million pregnancies that occur each year, about 46 million end in induced abortion (see Figure 3.2) ( 78 ).

Despite the large number of unintended pregnancies, many more women than ever before control their reproductive life by spacing their pregnancies more widely or limiting the number of pregnancies. Some 30 years of effort to bring contraceptive services within people’s reach have not been in vain. In developing countries, contraceptive prevalence has risen from around 10% in the early 1960s to 59% at the turn of the millennium ( 79 ). Despite falling international financial support, there has been a 1% annual increase in contraceptive prevalence over the last 10 years worldwide ( 80 ). A corresponding global drop in fertility has been seen, with the current average number of children per woman standing at 2.69, compared with 4.97 in the early 1960s ( 81 ).

Nevertheless, as more women than ever before reach reproductive age, millions who do not want a child or who want to postpone their next pregnancy are not using any contraception ( 82 ). This growing unmet need may be due to the lack of access to contraceptives, an issue in particular for adolescents, or it may result from women not using them. The most commonly given reason – in about 45% of cases – for not using a contraceptive method is a perceived lack of exposure to pregnancy. Fear of side-effects and cost is a reason for non-use in about one third of cases. Opposition to use is a lesser but still significant reason for non-use, frequently attributed to the husband ( 83 ). For all of these reasons, uptake of contraception is still very low in many parts of Africa, and patchy in other continents. According to recent survey data some countries are actually experiencing a reversal in family planning coverage.

Even if all the needs for contraception were met, there would still be many unwanted and mistimed pregnancies. Although most modern methods of contraception are highly effective if used consistently, advice and counselling on their correct use is often not available. If all users were to follow instructions perfectly, there would still be nearly 6 million accidental pregnancies per year. The fact is that with typical, real-life use of contraceptives, an estimated 26.5 million unintended pregnancies occur each year because of inappropriate use or method failure ( 84 ). In addition, dissatisfaction with methods can lead to discontinuation, which is often associated with lack of choice, incorrect use or fear of side effects, all symptoms of poor quality family planning counselling and services.

What the research on unmet need for contraception and on contraceptive failure does not capture well is the role of unequal power relations between men and women. These contribute substantially to both unwanted sex and subsequent unwanted pregnancy ( 85 ). Young women are at particular risk of unwanted sex, or sex in unwanted conditions, particularly when there are large age differences between them and their partners ( 85 ). Between 7% and 48% of adolescent girls report that their first sexual experience was forced ( 86 , 87 ). Adolescent girls are more likely to be pressured into sexual activity at an older man’s request or by force, and often must rely on the man to prevent pregnancy. Women who are coerced into sex or who face abuse from partners are less likely to be in a position to use contraception, and are therefore more exposed to unintended pregnancy than others. Women who have experienced a sexual assault often fear pregnancy and delay medical examination or health care. There is increasing evidence that violence is associated with unintended pregnancies. Up to 40% of women attending for pregnancy termination have experienced sexual and/or physical abuse at some stage of their lives ( 88 , 89 ).

Unintended and unwanted pregnancies – owing to unmet need for contraception, to contraceptive failure, or to unwanted sex – if brought to term, carry at least the same risks as those that are desired and deliberate. It is estimated that up to 100 000 maternal deaths could be avoided each year if women who did not want children used effective contraception ( 90 ). When maternal illnesses are also taken into account, preventing unwanted pregnancies could avert, each year, the loss of 4.5 million disability-adjusted life years ( 91 ).

The implications of unwanted pregnancy are substantial enough, but there is also evidence to suggest that effective contraception can contribute to better maternal health – above and beyond averting these deaths and disabilities – in two ways. First, because unwanted pregnancies carry a greater risk than those that are wanted. By tackling unmet need for contraception for young girls and for older women and also for those who want to space their births, high-risk pregnancies that are unwanted can be avoided. Moreover, there are benefits for the child. Spacing pregnancies by at least two years increases the chance of child survival ( 92 ). Second, there are some indications that women whose pregnancy is wanted take more care of their pregnancy than others: they are more likely to receive antenatal care early in pregnancy, to give birth under medical supervision, or to have their children fully vaccinated ( 90 ). Finally, a major contribution of contraception to reducing maternal death and disability is through its potential to decrease unsafe abortions.

Unsafe abortion: a major public health problem

Of the 46 million pregnancies that are terminated each year around the world, approximately 60% are carried out under safe conditions. From a public health viewpoint the distinction between safe and unsafe abortion is important. When performed by trained health care providers with proper equipment, correct technique and sanitary standards, abortion carries little or no risk. The case fatality is no more than 1 per 100 000 procedures ( 78 , 84 ), which is less than the risk of a pregnancy carried to term in the best of circumstances.

However, more than 18 million induced abortions each year are performed by people lacking the necessary skills or in an environment lacking the minimal medical standards, or both, and are therefore unsafe ( 93 , 94 ). Almost all take place in the developing world. With 34 unsafe abortions per 1000 women, South America has the highest ratio, closely followed by eastern Africa (31 per 1000 women), western Africa (25 per 1000 women), central Africa (22 per 1000 women), and south Asia (22 per 1000 women) ( 93 ). The fact that women seek to terminate their pregnancies by any means available in circumstances where abortion is unsafe, illegal or both, demonstrates how vital it is for them to be able to regulate their fertility. Women pay heavily for unsafe abortions, not only with their health and their lives but financially as well. In Phnom Penh, Cambodia, for example, the going rate for an abortion – legal, but most often unsafe – ranged between US$ 15 and US$ 55 in 2001: the equivalent of several months’ salary for a public sector nurse ( 95 ).

Unsafe abortion is particularly an issue for younger women. Two thirds of unsafe abortions occur among women aged between 15 and 30 years. Around 2.5 million, or almost 14% of all unsafe abortions in developing countries, are among women under 20 years of age. The age pattern of unsafe abortions differs markedly from region to region. The proportion of women aged 15–19 years in Africa who have had an unsafe abortion is higher than in any other region and almost 60% of unsafe abortions are among women aged less than 25 years. This contrasts with Asia where 30% of unsafe abortions are in women of this age group. In the Caribbean and Latin America, women aged 20–29 years account for more than half of all unsafe abortions ( 93 ).

Everywhere, though, and in all age groups, the consequences are dramatic. The risk of dying from an unsafe abortion is around 350 per 100 000, and 68 000 women a year die in this way. In addition, the non-fatal complications and the sequelae contribute significantly to the global burden of disease ( 96 ), not to mention the emotional turmoil that goes with so many unsafe abortions ( 97 ). Unsafe abortions also result in high costs for the health system. In some developing countries, hospital admissions for complications of unsafe abortion represent up to 50% of obstetric intake ( 98 , 99 ). In Lusaka, Zambia, they represent 27% of non-delivery referrals to the obstetric-gynaecological services ( 10 ). The mobilization of hospital beds, blood supplies, medication, operating theatres, anaesthesia and medical specialists is a serious drain on limited resources in many countries ( 84 ). The daily cost of a patient hospitalized as a result of unsafe abortion can be more than 2500 times the daily per capita health budget ( 100 ).


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