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Microsoft word - expert opinion final 14 06 2010 .doc

TECHNICAL OPINION
Action Canada for Population and Development (ACPD) UNDP/UNFPA/WHO/World Bank Special Programme of
Research, Development and Research Training in Human
Reproduction (HRP)
Department of Reproductive Health and Research,
World Health Organization, Geneva
9 June 2010
Background

Ms. Catherine McDonald, Executive Director of Action Canada for Population and
Development (ACPD) contacted Dr. Michael Mbizvo, Director a.i. of the Department of
Reproductive Health and Research, World Health Organization (WHO) for a WHO technical
opinion relating to safe abortion and maternal health, in connection with submissions to
inquiries by Canadian Parliamentary Committees.
Action Canada for Population and Development (ACPD) is a non-governmental non-profit
organization (NGO) based in Ottawa, Canada that seeks to enhance the quality of life of
women, men and children by promoting progressive policies in the field of international
development with a primary focus on reproductive and sexual rights and health and an
emerging focus on international migration and development. ACPD is an NGO in special
consultative status with the Economic and Social Council of the United Nations and has been
engaged in human rights work at the international and domestic levels.
Ms. McDonald explained in her request, that Canada is the host of this year’s G8 Summit and
as the host, the Prime Minister of Canada announced his intention to make maternal and child
health a development priority for the upcoming G8 Summit. Since this announcement, there
has been a great deal of Parliamentary scrutiny of the various proposals put forward by the
government as to what will be part of this maternal and child health initiative. Currently the
Prime Minister’s signature G8 initiative is the subject of inquiries by two Canadian
parliamentary Committees: The House of Commons Standing Committee on the Status of
Women and the House of Commons Standing Committee on Foreign Affairs and
International Development. One of the major issues that these Parliamentary Committees
have been considering within these inquiries is with respect to the role of access to safe
abortion services in realizing maternal health. Ms. McDonald has very recently testified
before both Standing Committees in their inquiry on the G8 Maternal and Child Health
initiative. Her appearance as a witness before these two Parliamentary Committees will be
supplemented by a written submission that ACPD will be making to these committees.
To inform the submissions to these two Parliamentary Committees, Ms. McDonald requested
an expert opinion from the World Health Organization on the following questions:
- What is the role of safe abortion in realizing maternal health?
- What are the health implications of lack of access to safe abortion services?
- Would the need for safe abortion services be eliminated even if there were
widespread access to all other reproductive health services?
- In the WHO’s opinion, are safe abortion services necessary to eliminate
preventable maternal mortality and morbidity and to achieve MDG 5?
- What is the nature and scope of international legal obligations and
commitments of Governments to eliminate unsafe abortion and to provide
access to safe abortion services?


ACPD intends to annex a copy of the expert opinion to its submission for transparency.
Submissions to Parliamentary Committees are publicly available documents and ACPD
intends to make its submission with annexes publicly available.


II. In response to the questions

- What is the role of safe abortion in realizing maternal health and what are the
health implications of lack of access to safe abortion services?

Globally, unsafe abortion accounts for 13 % of maternal deaths and 20% of the total mortality
and disability burden due to pregnancy and childbirth.4 In some countries, deaths due to
abortion account for as much as 30% of all maternal deaths.1
Each year, an estimated 210 million women throughout the world become pregnant and a
significant percentage of them (20%) resort to abortion. It is estimated that 42 million
abortions are performed annually, corresponding to 29 abortions per 1,000 women aged 15-44
years. Of these 42 million, 48% (20 million) are estimated to be unsafe abortions, i.e., they
are done by unskilled practitioners, or under unhygienic conditions, or both.2
In contexts where unsafe abortion is more widely prevalent, mortality due to unsafe abortion
is high. Unsafe abortion causes a significant proportion of maternal deaths. Nearly 70 000
women die each year due to the complications of unsafe abortion. 3 For example, 750 women
die per 100,000 unsafe abortions in sub-Saharan Africa compared to less than 1 (0.6) per
100,000 legal abortions in the USA.4 Globally, it has been estimated that in addition to some
70,000 women who die each year as a consequence of unsafe abortion, a further 5 million
suffer temporary or permanent disability.5 High levels of unintended pregnancies are the root
cause for women’s recourse to abortion. The reasons for unintended pregnancies are several
and include lack of access to or non-use of a contraceptive method as well as failure of the
method.
Better public policies can provide a legal and social environment that is more or less
favourable to health outcomes.6 Ready access to contraception and to early, safe abortion
significantly reduces high rates of maternal mortality and morbidity; it prevents the costs
currently imposed by unsafe abortion on health systems and on society and individuals; it
provides care for women who are not yet well served by family planning programmes or for
whom contraception has failed.7
Abortions performed in an illegal context, or in a context with poor availability or quality of
services, are likely to be unsafe. Poor women, young women, and those affected by crises
and conflicts are particularly at risk. Where there are few restrictions on the availability of
1 Khan KS, Wodyla D, Say L, Gülmezoglu AM, Van Look PFA. WHO analysis of causes of maternal death: a systematic review. Lancet, 2006; 367:1066-74. 2 World Health Organization. (2007) Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003. Geneva: World Health Organization. 3 World Health Organization. (2009) Women and health: today's evidence tomorrow's agenda. Geneva: World Health Organization. 4 World Health Organization. (2007) Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003. Geneva: World Health Organization. 5 Shah I, Åhman E. Unsafe abortion: global and regional incidence, trends, consequences, and challenges. JOGC, December 2009: 1149-1158. 6 World Health Organization. (2008) The world health report 2008 (Primary health care: now more than ever). Geneva: World Health Organization. 7 World Health Organizations. (2003) Safe abortion: technical and policy guidance for health systems. Geneva: World Health Organization. safe abortion, deaths and illness are dramatically reduced.8 The degree of legal access to abortion along with the availability and quality of legal abortion services co-determines the frequency and related mortality of unsafe abortion.9 Global data on abortion suggest that legal restrictions do not affect overall abortion rates; but, they do increase the proportion of unlawful and unsafe procedures.10 Women who seek an abortion will do so regardless of legal restrictions and/or the availability of safe services.11 In addition, restrictive laws, regulations, and/or policies can lead women to seek abortion in other countries with more liberal access to safe services, which is costly, delays the timing of an abortion, and results in social inequities. In South Africa, a change in legislation increased women's access to a broad range of options for the prevention and treatment of unwanted pregnancy, resulting in a 91% drop in abortion-related deaths.12 Following legal reform and the subsequent availability of safe services in the USA in 1973, abortion-related mortality declined by 73% from 1972-1976.13 Following legal reform and the subsequent availability of safe services in Romania in 1990, abortion-related mortality declined by 77% from 1989 to1993.14 Except for a very small number of countries in the world, most countries permit termination of pregnancy under certain legal grounds that can range from a very restricted set of conditions (for example, only after rape or incest, or to save the life of the woman) to few or no restrictions (that is, abortion on request). Where legal grounds for abortion exist, providers and health facilities should be trained and equipped to provide safe, induced abortion.15 In contexts where safe abortion is not legally permitted, or good-quality services are not available, complications from unsafe abortion are common and include sepsis, hemorrhage and other major life threatening consequences.16 To mitigate suffering and death from unsafe abortion, governments should provide emergency postabortion care. Such care should be provided by well trained and equipped providers using WHO-recommended methods for uterine evacuation -- vacuum aspiration or misoprostol for first-trimester incomplete abortion and, for second-trimester incomplete abortion, misoprostol and/or dilatation and evacuation.17 Timely care, positive provider attitudes, contraceptive counselling and methods, and 8 World Health Organization. (2009) Women and health: today's evidence tomorrow's agenda. Geneva: World Health Organization. 9 World Health Organization. (2007) Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003. Geneva: World Health Organization. World Health Organization. (2008) The world health report 2008 (Primary health care: now more than ever). Geneva: World Health Organization. 10 Sedge G, Henshaw S, Singh S, Ahman E, Shah IH. (2007) Induced abortion: estimated rates and trends worldwide. Lancet 370:1338-45. 11 World Health Organization. (2009) Women and health: today's evidence tomorrow's agenda. Geneva: World Health Organization. 12World Health Organization. (2008) The world health report 2008 (Primary health care: now more than ever). Geneva: World Health Organization. 13 Bartlett LA et al. Risk factors for legal induced abortion-related mortality in the United States. Obstetrics and Gynecology, 2004; 103(4):729-737. 14 Ministry of Health Romania, Centre for Health Statistics. National maternal mortality statistics. Bucharest: Ministry of Health, 1993. 16 World Health Organization. (2007) Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003. Geneva: World Health Organization. World 17 World Health Organization. (2003) Safe abortion: technical and policy guidance for health systems. Geneva: World Health Organization. screening, treatment and referral for other sexual and reproductive health needs are all critical components of postabortion care.18 - Are safe abortion services necessary to eliminate preventable maternal mortality and
morbidity and to achieve MDG 5?
The UN Millennium Development Goals, adopted by 189 nations, include the goal of improving maternal health and the specific target of reducing the maternal mortality ratio by three-quarters between 1990 and 2015. As noted previously, unsafe abortion is a major cause of maternal mortality; nearly 70 000 women die each year due to the complications of unsafe abortion,19 thus, measuring its incidence is important for monitoring progress on this goal. Unsafe abortion also has other consequences, including economic costs to health systems and families, stigmatisation, and other effects on women.20 The goal of eliminating unsafe abortion is central to reducing maternal mortality and therefore to achieving the ICPD Programme of Action and Millennium Development Goal 5 to improve maternal health. 21 - Would the need for safe abortion services be eliminated even if there were
widespread access to all other reproductive health services?
WHO endorses the definition of reproductive health outlined in the Programme of Action of the International Conference on Population and Development: "Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a health infant. In line with the above definition of reproductive health, reproductive health care is defined as the constellation of services that contribute to reproductive health and well-being by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases." (Paragraph 7.2)22 Furthermore, WHO endorses the integration of sexual and reproductive health services: 18 World Health Organization. (2003) Safe abortion: technical and policy guidance for health systems. Geneva: World Health Organization. 19 World Health Organization. (2009) Women and health: today's evidence tomorrow's agenda. Geneva: World Health Organization. 20 Sedgh G., Henshaw S, Singh S, Åhman E, Shah I. Induced abortion: estimated rates and trends worldwide. Lancet 2007; 370:1338-45. 21 World Health Organization. (2004) Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. Geneva: World Health Organization. 22 United Nations. Report of the International Conference on Population and Development, Cairo, 5-13 September 1994. New York: United Nations, 1995. "The core aspects of reproductive and sexual health are: improving antenatal, perinatal, postpartum and new born care; providing high-quality services for family planning, including infertility services; eliminating unsafe abortion; combating sexually transmitted infections including HIV, reproductive tract infections, cervical cancer and other gynaecological morbidities; and promoting sexual health. Because of the close links between the different aspects of reproductive and sexual health, interventions in one area are likely to have a positive impact on the others. It is critical for countries to strengthen existing services and use them as entry points for new interventions, looking for maximum synergy." 23 Use of effective contraception is the best way to prevent unintended pregnancy and recourse to abortion. Family planning saves lives, improves long-term health and productivity, and reduces costs associated with unwanted pregnancy and unsafe abortion.24 If women's needs for contraception were fully met: - safe and legal abortions would decline by 66% -- from 15 million to 5.1 million, - unsafe abortions would decline by 73% -- from 20 million to 5.5 million, - the number of women requiring treatment for abortion complications would decline by 73% -- from 8.5 million to 2.3 million.25 However, use of effective contraception reduces but does not eliminate the unwanted pregnancy and the demand for induced abortion.26 No contraceptive method is 100% effective in preventing pregnancy. Among the 712 million women using any method in 2007, 33 million are estimated to become accidently pregnant because of method- or user-failure and an additional 7 million even when they use the method correctly and consistently.27 Women suffering contraceptive failure require access to safe abortion services, if they cannot access safe services, they are likely to seek unsafe services.28 Despite its necessity, access to contraception and comprehensive sexuality education remain restricted by laws and policies in many countries. Even where there are enabling laws and policies on access to contraception and abortion, services are often not accessible for adolescents or unmarried adults, because of legal restrictions, misperception about the law and stigma attached to premarital sexual activity.29 23 World Health Organization. (2004) Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. Geneva: World Health Organization. 24 Singh S, Darroch JE, Ashford LS, Vlassoff M. Adding it up: the costs and benefits of investing in family planning and maternal and newborn health. New York: Guttmacher Institute, 2009. 25 Singh S, Darroch JE, Ashford LS, Vlassoff M. Adding it up: the costs and benefits of investing in family planning and maternal and newborn health. New York: Guttmacher Institute, 2009. 26 World Health Organization. (2003) Safe abortion: technical and policy guidance for health systems. Geneva: World Health Organization. 27 World Health Organization. Safe abortion: technical and policy guidelines for health systems. Geneva: World Health Organization, Forthcoming. 28 World Health Organization. (2009) Women and health: today's evidence tomorrow's agenda. Geneva: World Health Organization. 29 Grimes D, Benson J, Singh S, Romero M, Ganatra B, Okonofua F, Shah I. Unsafe abortion: the preventable pandemic. Lancet, 2006; 368: 1908-1919. - What is the nature and scope of international legal obligations and commitments of
Governments to eliminate unsafe abortion and to provide access to safe abortion
services?

As far back as 1967, the WHO recognized that unsafe abortion constituted a serious public health problem in many countries. The World Health Assembly, through its resolution WHA 20.41, urged the Organization to assist Member States, upon their request, in the development of family planning services within the basic health services.30 The recommendations agreed at the International Conference on Population and Development (ICPD) are reflected in the work by WHO. More specifically, the ICPD Programme of Action urged governments and other relevant organizations “to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family planning services” (paragraph 8.25).31 It further states “Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. Post-abortion counselling, education and family planning services should be offered promptly, which will also help to avoid repeat abortions.” The Fourth World Conference on Women in Beijing affirmed these agreements and also called upon Governments to consider reviewing laws containing punitive measures against women who have undergone illegal abortion (paragraph 106).33 The key actions adopted by the Twenty-first Special Session of the United Nations General Assembly for the further implementation of the ICPD Programme of Action noted: “In recognizing and implementing of the above, and in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women’s health.” (paragraph 63, iii).34 At the Beijing Conference in 1995, governments agreed to consider reviewing laws containing punitive measures against women who have undergone illegal abortion. United Nations Human Rights Treaty Monitoring Bodies have also expressed concern over illegal and unsafe abortions and in this context, the CEDAW Committee, the Committee on the Rights of the Child, the Human Rights Committee, and the Committee on Economic, Social and Cultural Rights have explicitly asked States to review legislation criminalizing abortion. Regional bodies, such as the Parliamentary Assembly of Europe called for similar action. http://www.ohchr.org/en/hrbodies/Pages/HumanRightsBodies. 30 World Health Assembly Resolution 20.41 1967. 31 United Nations. Report of the International Conference on Population and Development, Cairo, 5-13 September 1994. New York: United Nations, 1995. 32 United Nations. Report of the International Conference on Population and Development, Cairo, 5-13 September 1994. New York: United Nations, 1995. 33 United Nations. Report of the Fourth World Conference on Women, Beijing, 4-15 September 1995. New York: United Nations, 1996. 34 United Nations. Key actions for the further implementation of the Programme of Action of the International Conference on Population and Development. New York: United Nations, 1999. Almost all of the United Nations Human Rights Treaty Monitoring Bodies have addressed
illegal, unsafe abortion and high rates of maternal mortality in the context of the various
human rights treaties and have expressed concern over the impact of unsafe abortion-related
deaths on women’s rights to life and health. The CEDAW Committee and the Human Rights
Committee have taken the lead in calling States to eliminate restrictions on abortion as an
issue of violation of women’s right to non-discrimination and right to life and linked lack of
access to contraceptive information and family planning services—and women’s resulting
reliance on unsafe and illegal abortion—to high rates of maternal mortality. The Committee
Against Torture, in the context of a particular State practice said that forcing women to resort
to unsafe abortion constitutes cruel and inhumane treatment.35
The United Nations Human Rights Treaty Monitoring Bodies have addressed particular
barriers women face in attempting to access legal abortion services. The CEDAW Committee
called on States not to restrict women's access to health services or to the clinics that provide
those services on the ground that women do not have the authorization of husbands, partners,
parents or health authorities, because they are unmarried or because they are women. 36
The United Nations Human Rights Treaty Monitoring Bodies repeatedly addressed
adolescent's access to sexual and reproductive health services in the context of the right to the
highest attainable standard of health without discrimination on the ground of age and sex, in
the context of the best interest of the child, recognizing the evolving capacity of the child and
adolescents' right to privacy and confidentiality. Among other United Nations Human Rights
Treaty Monitoring Bodies, the Committee on the Rights of the Child has implicitly
acknowledged the connection between adolescents’ lack of access to family planning
information and services and maternal mortality resulting from high rates of teen pregnancy
and unsafe abortion, and has recommended greater access to adolescent reproductive health
programs and services as a means to reduce maternal mortality.37
The CEDAW Committee, among other Committees, has found that provisions that allow
conscientious objection without ensuring women alternate access to abortion violate women’s
human rights. 38
International and regional consensus documents and the United Nations Human Rights Treaty
Monitoring Bodies have repeatedly called upon States to provide post-abortion care as part of
comprehensive sexual and reproductive health services. The Committee against Torture
found in the context of a particular State's practice, that coercing confessions from women
seeking lifesaving, emergency medical treatment after illegal abortions and with the use of
those confessions in the prosecutorial process constitutes to be a torture.39

Since ICPD and the Beijing World Conference on Women, a number of regional agreements
have also called on Governments to review and revise their laws on abortion.
The Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women
in Africa (2005), Article 14, section 2C calls on States Parties to take all appropriate
measures to: "Protect the reproductive rights of women by authorising medical [i.e., safe]
35 See: http://www.ohchr.org/en/hrbodies/Pages/HumanRightsBodies.aspx 36 Documents avalable on: http://www.ohchr.org/en/hrbodies/Pages/HumanRightsBodies.aspx 37 Documents avalable on: http://www.ohchr.org/en/hrbodies/Pages/HumanRightsBodies.aspx 38 Documents avalable on: http://www.ohchr.org/en/hrbodies/Pages/HumanRightsBodies.aspx 39 Documents avalable on: http://www.ohchr.org/en/hrbodies/Pages/HumanRightsBodies.aspx abortion in cases of sexual assault, rape, incest, and where the continued pregnancy
endangers the mental and physical health of the mother or the live of the mother or the
foetus."

The African Union Health Ministers Special Session to discuss issues related to improving
sexual and reproductive health agreed to a Programme of Action (2006) that calls for the
following strategic actions related to reducing the incidence of unsafe abortion:
"Compile and disseminate data on the magnitude and consequences of unsafe abortion;
Enact policies and legal frameworks to reduce incidence of unsafe abortion; Prepare and
implement national plans of action to reduce incidence of unwanted pregnancies and unsafe
abortion; Train service providers in the provision of comprehensive safe abortion care
services where national law allows; Refurbish and equip facilities for provision of
comprehensive abortion care services; Provide safe abortion services to the fullest extent of
the law; Educate communities on available safe abortion services as allowed by national
laws; Train health providers in prevention and management of unsafe abortion."
40

The Parliamentary Assembly of Europe Resolution 1607 (2008) invites member states of the
Council of Europe to: "Decriminalise abortion within reasonable gestational limits, if they
have not already done so; Guarantee women's effective exercise of their right of access to a
safe and legal abortion; Allow women freedom of choice and offer the conditions for a free
and enlightened choice without specifically promoting abortion; Lift restrictions which
hinder, de jure or de facto, access to safe abortion, and, in particular, take the necessary
steps to create the appropriate conditions for health, medical and psychological care and
offer suitable financial cover; Adopt evidence-based appropriate sexual and reproductive
health and rights strategies and policies, ensuring continued improvements and expansion of
non-judgmental sex and relationships information and education, as well as contraceptive
services, through increased investments from the national budgets into improving health
systems, reproductive health supplies and information; Ensure that women and men have
access to contraception and advice on contraception at a reasonable cost, of a suitable nature
for them and chosen by them; Introduce compulsory age-appropriate, gender-sensitive sex
and relationships education for young people (inter alia, in schools) to avoid unwanted
pregnancies (and therefore abortions);Promote a more pro-family attitude in public
information campaigns and provided counselling and practical support to help women where
the reason for wanting an abortion is family or financial pressure."
41

Accepting the WHO Constitution, States took the responsibility for the health of their
peoples, which can be fulfilled only by the provision of adequate health and social
measures.42 By ratifying various international, and regional human rights treaties States made
commitments to respect, protect and fulfill human rights, including the right to the highest
attainable standard of health. Furthermore, the United Nations Charter establish a
responsibility on States to engage in international cooperation and the Universal Declaration
on Human Rights UDHR) recognises the entitlement of each individual to the realisation of
his or her economic, social and cultural rights “through national effort and international
40 Special Session the African Union Conference of Ministers of Health, Maputo, Mozambique, 18-22 September 2006 41 Access to safe and legal abortion in Europe. Resolution 1607. Parliamentary Assembly, Council of Europe. 2008. 42 World Health Organization. (1948) Constitution of the World Health Organization. Geneva: World Health Organization. cooperation” (article 22). The Declaration on the Right to Development recognises, among others, that as a complement to efforts by developing countries, international cooperation is essential to provide these countries with appropriate means and facilities to foster their comprehensive development; and States have a duty to co-operate with each other in ensuring development and eliminating obstacles to economic, social and cultural rights “through national effort and international cooperation” (article 22). Treaty obligations reinforce political commitments made to international cooperation for sexual and reproductive health including at the ICPD, FWCW and the Millennium and World Summits.43 43 International Covenant on Economic, Social and Cultural Rights (1966), article 2.1; Convention on the Rights of the Child (1989),article 24.4; Convention on the Rights of Persons with Disabilities (2006), article 32. Platform for Action of the Fourth World Conference on Women, 1995, A/CONF.177/20/Rev.1. Programme of Action of the International Conference on Population and Development, 1994, A/CONF.171/13. UN Millennium Project, Public Choices, Private Decisions: Sexual and Reproductive Health and Millennium Development Goals, 2006. See in: Judith Bueno de Mesquita and Paul Hunt. International Assistance and cooperation in sexual and reproductive health. Human Rights Centre, University of Essex. 2008.

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