• Of the 36 - 53 million abortions performed around the world every year, 20 million are unsafe.
• 55,000 unsafe abortions are induced every day - one for every 7 births.
• 10 - 50% of unsafe abortions need medial care.
• Lacking this care, 80,000 women die of unsafe abortion every year, over 200 per day.
• 1 mother succumbs to unsafe abortion every 7 minutes.
• Unsafe abortions account for 13% of global maternal deaths
• 95% of unsafe abortions are carried out in developing counties and as much as 50% of the hospital budgets in some developing countries are diverted to treat complications related to unsafe abortions.

Latin America has the highest rate of unsafe abortions - 40/1000 women of reproductive age. They are estimated to cause one quarter of all maternal deaths in these countries.
Asia, with the largest population of any region, has the highest absolute number of unsafe abortions - about 9.2 million per year - although the estimated abortion rate is only 12/1000 women. Nearly half the world’s abortions take place in Asia, almost a third in South Asia alone (where we belong). Unsafe abortions lead to 40,000 maternal deaths each year in Asia.
Women in sub-Saharan Africa are, however, most likely to die while undergoing unsafe abortion; about 1 of every 150 abortions results in the woman’s death in this region.
Long-term heath problems caused by unsafe abortions include chronic pelvic pain, pelvic inflammatory disease, tubal blockage, infertility, ectopic pregnancy and poor outcomes in subsequent pregnancies. Such problems can limit women’s productivity inside and outside the home, constrain their ability to care for their children and adversely affect their sexual and reproductive lives.

Who seek abortion and why?
Most women seeking abortion are married women with children; they seek to limit family size or space births rather than to delay first births. Non-use of contraceptives accounts for the majority of unwanted pregnancies. In addition, between 8 and 30 million pregnancies each year result from contraceptive failure. Other factors women cite as reasons for unwanted pregnancy include lack of control over contraception, too many children, abandonment or an unstable family relationship and financial limitations.

Family planning services out of reach
Despite the fact that family planning services are more effective and available than ever before, estimates suggest that at least 350 million couples worldwide lack access to information about sterilization and the range of modern family planning methods. Prevention of unwanted pregnancies must always be given the highest priority and attempts should be made to eliminate the need for abortion in the first place. Around 120 - 150 million married women, who want to limit or space future pregnancies, are not using a contraceptive and have an unmet need for family planning services. If all women who said they wanted no more children had access to contraception, maternal deaths would drastically decrease.

Legislation and policies
National policies and legislation on abortion vary widely. Forty percent of the world’s population live in countries where induced abortion is permitted on request; 25% live in countries where abortion is permitted only if the woman’s life is in danger.
Restrictive legislation is associated with higher rates of unsafe abortion, proven dramatically by the Romanian experience from 1966 to 1990. Contrary to common belief, legalization of abortion does not increase abortion rates. The Netherlands has a non-restrictive abortion law, widely accessible contraceptives and free abortion services and still the lowest abortion rates in the world.
In India, the Medical Termination of Pregnancy (MTP) Act was implemented in 1972. Yet in 1989, of a total of 5.3 million abortions induced, 4.7 million took place outside approved health-care facilities. Legislation must therefore be accompanied by changes in the health services delivery structure. Early abortion could be carried out by appropriately trained staff (not necessarily doctors) at primary health centers. The number and location of approved facilities vary widely in India. Maharashtra has one approved institution for every 8,000 couples but Bihar has only one for 1,32,000. Even when facilities are available, rigid bureaucratic control, an inflexible attitude, inadequate funding and lack of training of providers are hindrances readily identifiable in our country.

The solutions

• Universal access to family planning.
• MTP services when required.
• Care for complications of unsafe abortion.
• Education of communities about reproductive health and unsafe abortions.
• Changes in policies to safeguard women’s reproductive health.

In order to reduce the current heavy toll of abortion related maternal death and morbidity, governments, international agencies, women’s groups and voluntary organizations must make concerted efforts. High priority should be given to the prevention of unwanted pregnancies through comprehensive, user-friendly reproductive services. In countries where abortion is legal, as in India, services should be available and accessible, particularly in the rural and impoverished areas and without unnecessary delays or bureaucratic formalities.
A planned post-abortion care strategy provides more effective care - and often at little or no additional cost. The vacuum aspiration technique, must be extended throughout all levels of the health-care system, particularly the primary care level. Those seeking care for abortion related complications must be provided contraceptive services. Training should eliminate the judgmental or punitive attitudes of health-care staff that often delays life-saving care of women with abortion complications. An effective post-abortion care plan ensures that women receive care that is complete, appropriate and prompt - the ‘CAP’ strategy.
Education of communities is critical for reducing the public health problem of unsafe abortion. The health education message should be based on the incidence and impact of unsafe abortion within communities and must be sensitive to people’s existing beliefs, attitudes and practices. It should offer information on the legal status of abortion, prevention of unwanted pregnancies, avoidance of unsafe abortion and the early recognition and appropriate treatment of abortion related complications.

Saving lives, resources and money
Planning and implementing an effective unsafe abortion case strategy does not mean that developing country health systems must devote a major share of their health resources to abortion care. In fact, providing improved care that is strategically planned for and effectively delivered is likely to consume fewer health resources than the ‘crisis management’ approach currently found in most countries. The changes needed are the same changes required to improve medical care for all pregnancy related emergencies. Addressing the problem of unsafe abortion would bring down maternal mortality as well. Either we act or we let the mothers die. It is unlikely that we have any other option.

References

1. Abortion: A Tabulation of Available Information. 3rd ed. Geneva: World Health Organization; 1997.
2. Unsafe Abortion [Population Reports, Vol. 25, No. 1]. Baltimore: Population Information Program, The Johns Hopkins School of Public Health; 1997.
3. The State of the World Population - 1997. New York: United Nations Fund for Population Activities; 1997.
4. Henshaw S. Abortion laws and practice worldwide. In: Abortion Matters - Proceedings of the International Conference on Reducing the Need and Improving the Quality of Abortion Services; Uttrecht, Netherlands; 1997.

[top] [index]