Doi:10.1016/s0140-6736(06)69481-6

Sexual and Reproductive Health 4
Unsafe abortion: the preventable pandemic
David A Grimes, Janie Benson, Susheela Singh, Mariana Romero, Bela Ganatra, Friday E Okonofua, Iqbal H Shah Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other Published Online
more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about November 1, 2006
19–20 million abortions are done by individuals without the requisite skills, or in environments below minimum DOI:10.1016/S0140-
medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women This is the fourth in a Series of
die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, six articles about sexual and
infection, and poisoning. Legalisation of abortion on request is a necessary but insuffi
cient step toward improving reproductive health
women’s health; in some countries, such as India, where abortion has been legal for decades, access to competent care Department of Obstetrics and
remains restricted because of other barriers. Access to safe abortion improves women’s health, and vice versa, as Gynecology, University of
documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception North Carolina School of
Medicine, Chapel Hill, NC
can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden 27599-7570, USA
impoverished health care systems, and indirect costs also drain struggling economies. The development of manual (Prof D Grimes MD); Ipas, Chapel
vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Hill, NC, USA (J Benson DrPH);
Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of The Guttmacher Institute, New
York, NY, USA (S Singh PhD);
morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain CONICET/Centro de Estudios de
toward women.
Estado y Sociedad, Buenos
Aires, Argentina
Introduction
(M Romero MD); Ipas, Pune,
India (B Ganatra MD); College of
Unsafe abortion is a persistent, preventable pandemic. Medical Sciences, University of
WHO defi nes unsafe abortion as a procedure for Panel 1: Key messages
Benin and International
terminating an unintended pregnancy either by Federation of Obstetricians and
1 An estimated 19–20 million unsafe abortions take place individuals without the necessary skills or in an environ- Gynaecologists, Benin City,
every year, 97% of these are in developing countries.
Nigeria (Prof F Okonofua MD);
ment that does not conform to minimum medical 2 Despite its frequency, unsafe abortion remains one World Health Organization,
standards, or both.1 Unsafe abortion mainly endangers Geneva, Switzerland
of the most neglected global public health challenges.
women in developing countries where abortion is highly 3 An estimated 68 000 women die every year from restricted by law and countries where, although legally unsafe abortion, and millions more are injured, many permitted, safe abortion is not easily accessible. In these [email protected]
settings, women faced with an unintended pregnancy 4 Leading causes of death are haemorrhage, infection, often self-induce abortions or obtain clandestine and poisoning from substances used to induce abortion.
abortions from medical practitioners,2 para medical 5 Access to modern contraception can reduce but never workers, or traditional healers.3 By contrast, legal abortion in industrialised nations has emerged as one of 6 Legalisation of abortion is a necessary but insuffi the safest procedures in contemporary medical practice, step toward eliminating unsafe abortion.
with minimum morbidity and a negligible risk of death.4 7 When abortion is made legal, safe, and easily accessible, As with AIDS, the disparity between the health of women women’s health rapidly improves. By contrast, women’s in developed and developing countries is stark. Unsafe health deteriorates when access to safe abortion is made abortion remains one of the most neglected sexual and reproductive health problems in the world today. This 8 Legal abortion in developed countries is one of the article will describe the scope of the problem of unsafe safest procedures in contemporary practice, with case- abortion, estimate its mortality and morbidity, document fatality rates less than one death per 100 000 the relation between laws and women’s health, estimate costs, and describe prevention strategies. The key 9 Manual vacuum aspiration (a handheld syringe as a suction source) and medical methods of inducing abortion have reduced complications.
Worldwide burden
10 Treating complications of unsafe abortion overwhelms Worldwide estimates for 1995 indicated that about impoverished health-care services and diverts limited 26 million legal and 20 million illegal abortions took resources from other critical health-care programmes.
place every year.5 Almost all unsafe abortions (97%) are in 11 The underlying causes of this global pandemic are developing countries, and over half (55%) are in Asia apathy and disdain for women; they suff er and die (mostly in south-central Asia; table).6 Reliable data for the prevalence of unsafe abortion are generally scarce, www.thelancet.com Published online November 1, 2006 DOI:10.1016/S0140-6736(06)69481-6
based studies in India11 revealed self-reported abortions Number of unsafe Unsafe abortions
Unsafe abortions
in 28% of women, which is higher than fi gures derived abortions
per 100 livebirths
per 1000 women
(thousands)
aged 15–44 years
from national service-delivery data.
Estimates show that women in South America, eastern Africa, and western Africa are more likely to have an unsafe abortion than are women in other regions. Unsafe abortion rates per 1000 women aged 15–44 years (fi gure 1) provide a more comparable measure of unsafe abortion by region. In Asia, south-central and southeastern regions have similar unsafe abortion rates (22 and 21 per 1000 women, respectively), whereas the rate is about half (12 per 1000) in western Asia and negligible in eastern Asia (where abortion is legal on request and easily available).
Source: WHO.6 *Japan, Australia, and New Zealand have been excluded from the regional estimates, but are included Temporal trends in unsafe abortion have been in the total for developed countries. N/A=none or negligible incidence.
inconsistent internationally (fi gure 2). Between 1995 and 2000, a decline of 5 or more percentage points took place Table: Global and regional estimates of annual incidence of unsafe abortion, 2000
in the unsafe abortion rate in eastern, middle, and western Africa, the Caribbean, and Central America. especially in countries where access to abortion is legally Other developing areas had no appreciable change in the restricted. Whether legal or illegal, induced abortion is usually stigmatised and frequently censured by political, Unsafe abortions vary substantially by age across religious, or other leaders. Hence, under-reporting is regions: adolescents (15–19 years) account for 25% of all routine even in countries where abortion is legally unsafe abortions in Africa, whereas the percentage in available.7,8 The use of varying terms, such as induced Asia, Latin America, and the Caribbean is much lower miscarriage (fausse couche provoqué),9 menstrual (fi gure 3). By contrast, 42% and 33% of all unsafe abortions regulation, mini-abortion, and regulation of a delayed or in Asia and Latin America, respectively, are in women suspended menstruation10 further compounds the aged 30–44 years, compared with 23% in Africa.13 For the problem of producing reliable and comparable estimates developing regions as a whole, unsafe abortions peak in of the prevalence of unsafe abortion.
women aged 20–29 years. On the basis of WHO estimates, Community studies around the world indicate a if current rates prevail throughout women’s reproductive higher magnitude of unsafe abortion than do health lifetimes, women in the developing world will have an statistics.3,11,12 In Zambia, the extent of maternal mortality average of about one unsafe abortion by age 45 years.13 from unsafe abortion is not generally known from Reasons for seeking abortion are varied: socioeconomic health statistics; one study in which women were concerns (including poverty, no support from the partner, interviewed revealed that 69% of the respondents knew and disruption of education or employment); family- one or more women who had died from an unsafe illegal building preferences (including the need to postpone abortion.12 Focus-group discussions and community- childbearing or achieve a healthy spacing between births); relationship problems with the husband or partner; risks to maternal or fetal health; and pregnancy resulting from rape or incest.14 More proximate causes include poor access to contraceptives and contraceptive failure.14 Deaths from unsafe abortion
Measurement of the worldwide prevalence of abortion- level, national vital registration systems routinely under- count such deaths.15 Calculation of the proportion of maternal deaths due to abortion complications is even more challenging. Abortion-related mortality often happens after a clandestine or illegal procedure, and powerful disincentives discourage reporting. As a result, linking specifi c programmatic interventions to changes in maternal mortality at a population level is rarely Number of unsafe abortions per 1000 women aged 15–44 years of deaths. Moreover, women might not report their Figure 1: Estimated number of unsafe abortions per 1000 women aged 15–44 years, by subregion
condition or might not relate it to a complication of an Source: WHO.6 Australia and New Zealand are excluded from estimates of Oceania.
www.thelancet.com Published online November 1, 2006 DOI:10.1016/S0140-6736(06)69481-6
ratio was estimated to be 60 in the year 2000. However, the ratio is much higher in eastern, middle, and western Africa (90–140), and is lower in northern and southern Africa, western and southeastern Asia, and Latin America and the Caribbean (10–40). Unsafe abortion is estimated to account for 13% of all maternal deaths worldwide, but accounts for a higher proportion of maternal deaths in Latin America (17%) and southeastern Asia (19%). Morbidity from unsafe abortion
Morbidity is a much more common consequence of unsafe abortion than mortality, but is determined by the Unsafe abortions per 1000 women aged 15–49 years same risk factors. Complications include haemorrhage, sepsis, peritonitis, and trauma to the cervix, vagina, Figure 2: Estimated number of unsafe abortions per 1000 women aged
uterus, and abdominal organs (fi gure 4). High proportions 15–49 years, by region, 1990–2000
of women (20–50%) who have unsafe abortions are Source: Special tabulations using WHO database on unsafe abortion.6 hospitalised for complications.17 National studies show that the rate of hospitalisation varies from a low of three per 1000 women per year (in Bangladesh, where menstrual regulation is legally permitted) to a high of Morbidity and hospitalisation rates have probably fallen since the early 1990s in response to safer abortion services. In Peru (1989–98) and in the Philippines (1994–2000), the abortion-related hospitalisation rate dropped—by 10% in the Philippines in 6 years and by 33% in Peru in 9 years— though the number of women hospitalised declined much more slowly.20 Increased use of misoprostol (replacing more invasive unsafe methods) probably partly accounts for reduced complications.21 In Brazil, the number of women treated in public hospitals for abortion Figure 3: Percentage distribution of unsafe abortions by age group in the
complications dropped by about 28% over 13 years (from developing world and regions
345 000 in 1992 to 250 000 in 2005).22 However, most of this decline took place between 1992 and 1995, and the number has varied little since then. Whereas increased use of Worldwide, an estimated 68 000 women die as a result misoprostol might have accounted for some of the early of complications from unsafe induced abortions every decline in abortion-related morbidity, the stability of the year—about eight per hour.6 This prevalence translates number suggests that most women who have an abortion into an estimated case-fatality rate of 367 deaths per 100 000 unsafe abortions, which is hundreds of times higher than that for safe, legal abortion in developed nations. This ratio is higher in Africa (709), lower in Latin America and Caribbean (100), and close to the worldwide average in Asia (324). These diff erences presumably indicate regional diff erences in the safety of abortion provision, the severity of complications, and access to care thereafter.6 By use of diff erent methods, a recent systematic review of causes of maternal mortality worldwide estimated that abortion accounted for 1–49% of such deaths.16 Irrespective of the research methodologies used, the public health message is clear: unsafe abortion kills large numbers of women.
About half of all deaths from unsafe abortion are in Asia, with most of the remainder (44%) in Africa.6 The unsafe abortion mortality ratio (the number of unsafe Figure 4: Loops of gangrenous small intestine protruding from the vagina
after attempted abortion, 20-year-old woman
abortion-related deaths per 100 000 livebirths) varies Source: Oye-Adeniran.106 Reproduced with permission from across regions. For the developing world as a whole, this Reprod Health Matters 2002; 10: 18–21.
www.thelancet.com Published online November 1, 2006 DOI:10.1016/S0140-6736(06)69481-6
Panel 2: Part inventory of unsafe abortion methods, by route of administration93
Treatments taken by mouth
Intramuscular injections
Foreign bodies placed into the uterus through the cervix
Boiled and ground avocado or basil leaves Black beer boiled with soap, oregano, and parsley Boiled apio (celery plant) water with aspirin Air blown in by a syringe or turkey baster Uterine stimulants, such as misoprostol or oxytocin (used Quinine and chloroquine (used for treating malaria) Oral contraceptive pills (ineff ective in causing abortion) Treatments placed in the vagina or cervix
with misoprostol still seek treatment at public hospitals 20–30% of unsafe abortions result in reproductive tract (Anibal Faundes, personal communication, July 5, 2006).
infections and that about 20–40% of these result in upper- Severity of complications is another important measure genital-tract infection and infertility. An estimated 2% of of eff ects on health. A standardised measure of the women of reproductive age are infertile as a result of severity of complications was used in South Africa before unsafe abortion, and 5% have chronic infections.6 Unsafe and after legalisation of abortion on request in 1996.23 abortion could also increase the long-term risk of ectopic The proportion of women classifi ed with severe pregnancy, premature delivery, and spontaneous abortion complications (fever of 38°C or more, organ or system in subsequent pregnancies. Little is known about women failure, generalised peritonitis, pulse 120 per min or who have complications but who do not seek medical care. more, shock, evidence of a foreign body, or mechanical Clinicians estimate that the proportion of such women injury) in South Africa fell substantially from 16·5% was 14% in Latin America, 19% in south and southeast before legalisation to 9·7% after. Applying similar Asia, and 26% in Nigeria.18 Similar studies in Guatemala methods, a study in Kenya found that 28% of hospitalised and Uganda yielded estimates of about 20%.19,25 women had severe complications. Gestational age at Delays in recognising the need for care and in arranging abortion is a simple predictor of risk: later abortions are transportation are common. On reaching a health-care associated with increased risks for the woman. Late facility, women with complications of unsafe abortion are abortions are common; for example, a third of women often met with suspicion or hostility. Their treatment is treated for abortion complications in public hospitals in deferred—sometimes indefi nitely.26 This disdain com- Kenya were beyond the fi rst trimester.24 By contrast, pounds the poor staff training, inoperative equipment, spontaneous abortions are uncommon after the fi rst out-of-stock drugs, sporadic supplies of water and trimester, suggesting that many of these complications electricity, and transportation challenges hampering stemmed from induced unsafe abortions.
developing-country health-care facilities. Information on long-term health consequences of Life-threatening sepsis or haemorrhage might mean a unsafe abortion is scarce. The WHO estimates that about hysterectomy. Gas gangrene from Clostridium perfringens www.thelancet.com Published online November 1, 2006 DOI:10.1016/S0140-6736(06)69481-6
is common with insertion of foreign bodies, and tetanus Legal status of abortion
threatens women who have not been immunised. Women Increasing legal access to abortion is associated with with retained tissue and severe infections might receive improvement in sexual and reproductive health. only oral tetracycline until they are deemed stable enough Conversely, unsafe abortion and related mortality are for curettage in an operating theatre; many die needlessly both highest in countries with narrow grounds for legal during the wait. Delays are especially dangerous when abortion.33 More than 61% of the world’s population bowel injuries cause peritoneal contamination.27 resides in countries where induced abortion is allowed without restriction or for a wide range of reasons such as Traditional methods
protection of the woman’s life, preservation of her Nearly 5000 years ago, the Chinese Emperor Shen Nung physical or mental health, and socioeconomic grounds.34 described the use of mercury for inducing abortion.28 In 72 countries, most of which are in the developing Although one publication18 lists over 100 traditional world, 26% of the world’s population lives where abortion methods used for inducing abortion, unsafe methods is prohibited altogether or allowed only to save the today can be divided into several broad classes: oral and woman’s life.34 Most of these restrictive laws originated injectable medicines, vaginal preparations, intrauterine from European colonial laws from previous centuries, foreign bodies, and trauma to the abdomen (panel 2). In although the European nations discarded their restrictive addition to detergents, solvents, and bleach, women in developing countries still rely on teas and decoctions Between 1995 and 2005, 12 countries increased access made from local plant or animal products, including to legal abortion, including Albania, Benin, Burkina Faso, dung. Foreign bodies inserted into the uterus to disrupt Cambodia, Chad, Ethiopia, Guinea, Guyana, Mali, Nepal, the pregnancy often damage the uterus and internal South Africa, and Switzerland.35,36 The strategies used to organs, including bowel. In settings as diverse as the achieve reform vary by country. Nepal’s reforms in 2002, South Pacifi c and equatorial Africa, abortion by abdominal for example, were part of an overall women’s rights bill massage is still used by traditional practitioners. The and permit legal abortion with no restriction in the fi rst vigorous pummelling of the woman’s lower abdomen is 12 weeks of pregnancy and afterwards on specifi c designed to disrupt the pregnancy but sometimes bursts grounds. The previous law allowed no indications for the uterus and kills the woman instead.29 abortion.35 The post-apartheid movement for expanded The primitive methods used for unsafe abortion show equality in South Africa led to the 1996 act that allows the desperation of the women. Surveys done in New legal abortion without restriction during the fi rst 12 weeks York City before the legalisation of abortion on request of pregnancy and afterwards on numerous grounds. documented the techniques in common use.30 Of Only narrow indications for legal abortion had been 899 women interviewed, 74 reported having attempted to previously allowed.35 In early 2006, Colombia’s consti- abort one or more pregnancies; 338 noted that one of tutional court ruled in favour of expanded indications for their friends, relatives, or acquaintances had done so. Of legal abortion, including when a woman’s life or health is those reported abortion attempts, 80% tried to do the in danger and in cases of rape or fetal malformation.37 abortion themselves. Nearly 40% of women used a combination of approaches. In general, the more Panel 3: Prosecution in El Salvador
invasive the technique, the more dangerous it was to the woman and the more likely it was to disrupt the “After I came out of the coma, they moved me to the pregnancy. Invasive methods, such as insertion of tubes maternity hospital. My brother visited and asked me if or liquids into the uterus, were more successful than the police had come to ask me questions. He said the were other approaches. Coat hangers, knitting needles, police had come to our house and they had interrogated and slippery elm bark were common methods; the bark our relatives and neighbours. They had gone to where I worked. They asked everyone a lot of questions about would expand when moistened, causing the cervix to me and who I was and if they knew whether I was open. Another widely used method was to place a fl exible pregnant and whether I’d had an abortion. rubber catheter into the uterus to stimulate labour. Surveys suggest that miscellaneous methods and oral When I got home, the prosecutor came to see me, and medications, such as laundry bleach, turpentine, and he asked lots of aggressive questions. He talked to me massive doses of quinine, were most commonly used in like I was a criminal. I didn’t want to answer because I New York.30 Injection of toxic solutions into the uterus was scared. He said if I didn’t answer, even though I with douche bags or turkey basters was common. was in bad physical shape, he would put me in jail. He Absorption of soap solutions into the woman’s circulation wanted me to tell him who the father of the child was could cause renal toxicity and death.31 Potassium and the name of the person who had done this to me. permanganate tablets placed in the vagina were also I didn’t know her name. Then he made a date for me to come to the prosecutor’s offi common; these did not induce abortion but could cause severe chemical burns to the vagina, sometimes eroding www.thelancet.com Published online November 1, 2006 DOI:10.1016/S0140-6736(06)69481-6
Advocacy for increased access to safe legal abortion has highest in countries where abortion is legally restricted. increased in countries such as Argentina, Brazil, In such countries, the median ratio for unsafe abortion Indonesia, Jamaica, Kenya, Mexico, Mozambique, mortality is 34 deaths per 100 000 livebirths; this ratio Nigeria, Trinidad and Tobago, Uganda, and Uruguay. steadily decreases as legal grounds for abortion increase. These eff orts are rooted in public health, human rights, The ratio falls to one or less per 100 000 livebirths in and other arguments. Those involved include health and countries that allow abortion on request.33 Even in medical professionals, women’s groups, legal and human countries where improved access to health care and rights advocates, young people, government offi emergency obstetric services has greatly reduced overall and, in some countries, trade unionists.38 maternal mortality, restrictive abortion laws translate Several countries have restricted abortion laws in the into abortion deaths constituting a disproportionately past decade. El Salvador amended its penal code in 1998 high share of maternal deaths (panel 4).41 to ban abortion for any legal indication; previous Making abortion legal, safe, and accessible does not indications had included saving a woman’s life, pregnancy appreciably increase demand. Instead, the principal eff ect resulting from rape, and fetal impairment (panel 3).35 In is shifting previously clandestine, unsafe procedures to 1997, Poland’s Parliament approved legislation removing legal and safe ones. Hence, governments need not worry social and economic grounds for abortion.35 Anti-abortion that the costs of making abortion safe will overburden the voices continue to protest against attempts at legal reform health-care infrastructure.18 Countries that liberalised in countries as diverse as Nicaragua, Sri Lanka, and their abortion laws such as Barbados, Canada, South Uruguay. The recent legislation for safer access in Africa, Tunisia, and Turkey did not have an increase in Colombia prompted a Roman Catholic cardinal to suggest abortion. By comparison, the Netherlands, which has civil disobedience and to threaten excommunication of unrestricted access to free abortion and contraception, judges who voted to support safer laws.39 has one of the lowest abortion rates in the world.18 In several countries, legal inquiry, prosecution, and Eff ect of law on health
even imprisonment of women who have had an unlawful The prevalence of unsafe abortions remains the highest abortion is not uncommon.40 Before the 2002 law change in the 82 countries with the most restrictive legislations, in Nepal, an estimated 20% of the women prisoners up to 23 unsafe abortions per 1000 women aged nationwide were in jail for charges relating to abortion or 15–49 years. By contrast, the 52 countries that allow infanticide. Many women who had miscarriage, abortion on request have a median unsafe abortion rate stillbirths, or induced abortions were jailed on charges of as low as two per 1000 women of reproductive age.33 Although the case-fatality rate from unsafe abortions Enabling abortion legislation is necessary but not indicates the general level of health care and the cient: a new law might not translate into widespread availability of post-abortion services, the rate remains the access to safe services. India and Zambia both legalised abortion in the early 1970s, but safe, legal abortion remains largely unavailable.46 In India, access through Panel 4: Romania and South Africa
the public health system is mainly restricted to cities. Widespread access to legal abortions on request in Romania from 1957 onwards led to a Despite a mandate to provide abortion services, in most decline in unsafe abortions with an abortion mortality ratio of 20 per 100 000 livebirths states fewer than 20% of primary health care centres do in 1960.6,42 Mortality began to rise steadily as Ceausescu’s pronatalist restrictive policy so. Many centres only sporadically provide service either imposed in 1966 began to take eff ect (fi gure 5). By 1989 mortality ratios had risen seven- because of a shortage of trained physicians or functioning fold to peak at 148 deaths per 100 000 livebirths; abortion accounted for 87% of the deaths. When Ceausescu was deposed in 1989, the immediate change of laws reversed Access to safe abortion is also mediated by women’s this trend. The mortality ratio fell by more than half to 68 within the fi rst year of safer awareness of the law. Knowledge is often poor, even in access itself. By 2002, mortality from unsafe abortions was as low as nine per countries with longstanding liberal laws. Misperceptions 100 000 livebirths; abortion deaths accounted for less than half of maternal deaths.43 about the specifi cs of the law are not uncommon, thus Abortion became legal and available on request in South Africa in 1997.44 The Choice on making women vulnerable to poor care, fi nancial Termination of Pregnancy act No 92 was promulgated in South Africa on Oct 31, 1996, but exploitation, and prosecution.45,48,49 Even where legal went into eff ect on Feb 1, 1997. Since then, the resulting favourable environment has abortion is widely available on request, misperceptions increased women’s access to family planning, abortion, and post-abortion care services in about the legality of minors having sexual intercourse the country. After the law was passed, abortion-related deaths dropped 91% from 1994 to delay some adolescents from seeking care. In many cultures, perceptions of legality are aff ected by the stigma attached to premarital or extramarital sexual activity. In The new law increased women’s access to a broad range of options for the prevention and several south Asian countries, such pregnancies are treatment of unwanted pregnancy. In particular, the law led to the increased promotion commonly referred to as illegal or illegitimate, as are the of family planning, the increased use of manual vacuum aspiration for abortion and post- abortions induced in these circumstances.50 Misperceptions abortion care, use of manual vacuum aspiration by nurses and midwives, and the about legal requirements, such as the need for spousal introduction of medical abortion methods.
authorisation and provider attitudes, could create barriers www.thelancet.com Published online November 1, 2006 DOI:10.1016/S0140-6736(06)69481-6
that do not exist in law. These, in turn, might drive unmarried women to unsafe providers (compromising medical safety for confi dentiality47,51) or to suicide.52 Percentage of maternal deaths caused by abortion Costs of unsafe abortion
Treatment of abortion complications burdens public health systems in the developing world. Conversely, ensuring women’s access to safe abortion services lowers medical costs for health systems. In some low-income and middle-income countries, up to 50% of hospital budgets for obstetrics and gynaecology are spent treating complications of unsafe abortion.18 A review of medical records in 569 public hospitals in Egypt during 1 month noted that almost 20% of the 22 656 admissions to obstetrics and gynaecology departments were for treatment of an induced or reportedly spontaneous abortion.53 Direct costs include health personnel, medications, blood, supplies and equipment, and overnight stays. The cost per woman to health systems for treatment of abortion complications in Tanzania is more than seven times the overall Ministry of Health budget per head of population.54 Estimates from Uganda comparing costs of treatment of abortion complications with costs of Figure 5: Livebirths and proportion of maternal deaths due to abortion, Romania, 1965–90
providing safe, elective abortion show the potential Source: David.42 Data unavailable for 1979.
resource-savings to health systems. Post-abortion care off ered in tertiary hospitals by physician providers was productivity from abortion-related morbidity and mortality estimated to cost health systems ten times more than on women and household members; the eff ect on elective abortion services off ered by mid-level practitioners children’s health and education if their mother dies; the in primary care (Heidi Johnston, 2004; Ipas, Chapel Hill, diversion of scarce medical resources for treatment of abortion complications; and secondary infertility, stigma, In sub-Saharan Africa, two studies attempted to estimate and other sociopsychological consequences. For example, costs at the national level. A 1997 South African study an estimated 220 000 children worldwide lose their mothers estimated that the total yearly cost of treating unsafe every year from abortion-related deaths.59 Such children abortion morbidity in public hospitals was ZAR receive less health care and social care than children who 9·74 million (about US$1·4 million).55 A 2002 study in have two parents, and are more likely to die.60 Nigeria estimated that the total national cost of direct Estimates of disability adjusted life-years (DALYs) provide medical care for treating abortion complication patients an indicator of one part of the indirect costs, women’s loss was NGN 1400 million ($11·7 million).56 A second study in of productive life. An estimated 5 million DALYs are lost Nigeria estimated that the national cost of treating unsafe per year by women of reproductive age as a result of abortion complications in 2005 was $19 million (Akinrinola mortality and morbidity from unsafe abortion.61 However, this rate probably underestimates the true burden because Use of manual vacuum aspiration for management of of limitations in the methods of estimating DALYs resulting fi rst-trimester incomplete abortions reduces costs. Studies in Bolivia, Mexico, and Peru showed that although the cost Stigma impairs health, both directly through harm to per patient for inpatient dilatation and curettage services wellbeing and indirectly by hindering prompt access to ranged from $66–151, a change to ambulatory manual medical care. Stigma related to abortion particularly aff ects vacuum aspiration reduced costs to $33–66, a decrease of adolescents and unmarried women because of their 56–72%.57 Per-patient costs in Kenya fell by 23% in one inexperience and few economic resources.26 Social hospital and 66% in another when post-abortion care sanctions against sexual activity are especially problematic services were changed from dilatation and curettage to manual vacuum aspiration in outpatients.58 Reductions in overall costs per patient were attributable to shortened Levels of prevention
hospital stays, less staff time, and fewer medications. Preventive medicine is traditionally viewed in three levels.62 Primary prevention (the domain of public health) Indirect costs
protects health by personal and community eff orts, such The indirect costs of unsafe abortion are substantial, yet as lowering serum cholesterol and discouraging cult to quantify. They include the loss of smoking. Secondary prevention (the domain of www.thelancet.com Published online November 1, 2006 DOI:10.1016/S0140-6736(06)69481-6
preventive medicine) includes early detection and on the use of a simple syringe with a plunger to generate prompt treatment of disease, for example, acute cardiac negative pressure for uterine evacuation, and plastic care for myocardial infarction. Tertiary prevention cannulas of varying sizes. The amount of negative (rehabilitation) mitigates disability, an example being pressure obtained with manual vacuum aspiration is coronary artery bypass grafting. In general, primary similar to that generated with large, expensive, electrical prevention is preferable to secondary and tertiary pumps, which makes this method especially suited for prevention in terms of both cost and compassion: immunising against poliomyelitis is better than building vacuum aspiration also has the advantage that the syringe can be cleaned, high-level disinfected, or sterilised and Primary prevention includes reduction in the need for used repeatedly; similarly, cannulas can be discarded or unsafe abortion through contraception, legalisation of re-used after appropriate disinfection or sterilisation.
abortion on request, the use of safer techniques, and Vacuum aspiration is safer than sharp curettage, and improvement of provider skills. Access to safe, eff ective the WHO recommends vacuum aspiration as the contraception can substantially reduce—but never preferred method for uterine evacuation before 12 weeks eliminate–the need for abortion to regulate fertility. The of pregnancy.67 This method is faster, safer, more eff ect of national contraceptive programmes on reducing comfortable, and associated with shorter hospital stay for the rate of abortion is well documented. In seven induced abortion than sharp curettage.73,74 Additional countries (Bulgaria, Kazakhstan, Kyrgyzstan, Switzerland, advantages compared with sharp curettage are its ease of Tunisia, Turkey, and Uzbekistan), abortion rates fell as use as an outpatient procedure, the need for less analgesia use of modern contraception rose.63 In another six and anaesthesia,75 and its lower cost per procedure countries (Cuba, Denmark, Netherlands, Republic of especially if done on an outpatient basis.76 In countries Korea, Singapore, and USA), abortion and contraception with a small number of physicians, vacuum aspiration increased simultaneously; the uptake of eff ective can be safely and eff ectively used by mid-level health contraception did not keep pace with couples’ increasing The combined use of mifepristone and misoprostol In several of the six countries, abortion rates ultimately has become the standard WHO-recommended medical declined with continued contraceptive use and regimen for early medication abortion,67 and is better stabilisation of fertility rates at lower levels. Even with than either drug alone.78 Misoprostol is a prostaglandin E 1 high rates of contraceptive use, however, unintended analogue marketed for the prevention and treatment of pregnancies will continue. No contraceptive method is gastric ulcers. However, mifepristone can be expensive 100% eff ective, and many couples in the developing and is not available in much of the world, whereas world still encounter obstacles to contraception.64 Every misoprostol is cheap and widely available. Regimens year, 80 million women worldwide have an unintended with misoprostol alone as an abortifacient have varied pregnancy, and 60% of these are aborted.18 Thus, the widely, with reported success rates ranging between 87% need for safe abortion will continue.
and 97%.79 Increased access to misoprostol has been The developing world has seen a revolution in contra- associated with improved women’s health in developing ceptive use—from a mere 9% of couples using any countries, and studies are being done to refi ne the method in 1960–6565 to 59% in 2003.66 Nevertheless, an regimen for misoprostol alone to induce abortion estimated 27 million unintended pregnancies happen worldwide every year with the typical use of contra- Secondary prevention entails prompt and appropriate ceptives. 6 million would happen even with perfect (ie, treatment of complications. This includes timely correct and consistent) use.67 An estimated 123 million evacuation of the uterus after incomplete abortion. WHO women have an unmet need for family planning.68 All abortion patients—whether seeking treatment of a complication or an elective induced abortion—should be off ered contraceptive counselling and a choice of appropriate methods. Results of many studies in Latin America and Africa have shown that after having an abortion patients will accept contraception at high rates.57,69-71 Contraceptive counselling and provision at the time of treatment reduced unintended pregnancies and repeat abortions by 50% over 1 year in Zimbabwe, compared with post-abortion patients who did not receive such services.72 The advent of vacuum aspiration in the 1960s1 revolutionised the primary prevention of complications in developing countries. This technology (fi gure 6) relies Figure 6: Manual vacuum aspiration syringe
www.thelancet.com Published online November 1, 2006 DOI:10.1016/S0140-6736(06)69481-6
has issued technical and clinical guidelines for the provision of safe abortion care67 and treatment of abortion Panel 5: Misoprostol in South America
complications.1 Misoprostol can be used for the After introduction into Brazil in 1986, misoprostol became available over the counter. management of incomplete abortion,86 and vacuum Soon, women recognised its eff ectiveness as an abortifacient and began to use the drug aspiration is better than sharp curettage.87,88 for this purpose. Women would self-administer the drug orally and then seek medical Post-abortion care is spreading worldwide. In assistance if the uterine bleeding did not stop. By 1990, 70% of women treated in Guatemala, with support from the Ministry of Health, hospital for abortion complications in Brazilian hospitals reported having used the Centro de Investigación Epidemiológica en Salud misoprostol.80 The report of a rapid increase in uterine evacuation procedures done in Sexual y Reproductiva began in 1996 a series of training- some hospitals as a result of abortions initiated by misoprostol81 led the Ministry of of-trainers with teams of nurses and doctors around the Health to restrict its sale in 1991. The State of Ceara banned the drug altogether. country. Content included post-abortion assessment and However, restricting access to the drug did not prevent its use; rather, the drug remained diagnosis, uterine evacuation procedures and techniques, widely available in the black market at infl ated prices. Consequently, the rate of abortion pain management, infection prevention, management of complications increased after restriction. Indeed, in Campinas, abortion-related deaths complications, referral to other sexual and reproductive tripled after restricted access to misoprostol.80 health services, contraceptive counselling and provision, Women’s use of misoprostol in Brazil decreased the severity of unsafe abortion complications, and to some extent also decreased the number of women admitted to The results of a survey in Addis Ababa showed that hospital. Previously, women would insert foreign bodies into their cervix, which provoked almost 30% of maternal deaths in the city resulted from bleeding and led to completion by curettage in hospital. Misoprostol is less likely to cause unsafe abortion.90 To address the high maternal mortality infection than are foreign bodies.82 One hospital recorded a rate of uterine infection of 4% rate (estimated to be 850 deaths per 100 000 livebirths), in women who reported using misoprostol, compared with 8% in women who reported the Ministry of Health, Regional Health Bureaus, and several international non-governmental organisations joined forces to improve post-abortion care in the public- Use of medical abortion has also expanded in Peru.84 Although the use of prostaglandins health sector. Interventions include clinical training of for abortion was infrequent in a 1989 survey, most key informants mentioned it in a physicians and midwives, provision of manual vacuum similar survey in 1998,85 even in remote regions of the country. The wide use of aspiration and other supplies, reorganisation of services, prostaglandins for abortion has been associated with improved health for women. In supervisory visits to facilities, and improved record- three other countries, women have widely accepted medical abortion because of its keeping. Post-abortion care was implemented in 42 health-care facilities in three regions assessed from 2000 to 2004. Quality of care also improved.91 In 2004, UN General Assembly in June, 1999, governments agreed Ethiopia revised its abortion law and in 2006 issued that “in circumstances where abortion is not against the guidelines for safe abortion services.
law, health systems should train and equip health-service Critics of post-abortion care worldwide complain that providers and should take other measures to ensure that the preoccupation with secondary (rather than primary) such abortion is safe and accessible”.97 By investing in prevention of unsafe abortion is myopic, tantamount to abortion safety and avail ability, governments throughout placing ambulances at the bottom of a cliff instead of the world can save the lives of tens of thousands of women Tertiary prevention mitigates long-term damage. Rapid Increasingly, private foundations and donor govern- transfer to a hospital can be lifesaving.92 Prompt repair of ments, including the UK, Netherlands, Sweden, Norway, uterine injury could preserve fertility. Acute renal failure Denmark, and Finland, have funded activities to advance and tetanus from unsafe abortions remain important access to safe abortion. By contrast, the USA has since causes of death and lengthy disability.93 Repair of fi stulas 1974 precluded use of development assistance for abortion in bowel and bladder can end the suff ering, stigmatisation, services. In 2001, the US government re-intro duced the and abandonment that these injuries cause.
even more restrictive Mexico City Policy, known by opponents as the Global Gag Rule. According to this The public health imperative
policy, private organisations outside the USA are eligible The public health rationale to address unsafe abortion was for family planning assistance only if they agree not to fi rst drawn to attention by the World Health Assembly engage in most abortion-related activities, even with their four decades ago.94 In 1994, the Programme of Action of the International Conference on Population and Develop- International organisations increasingly regard the ment stated, “In circumstances where abortion is not denial of safe abortion services as a human-rights violation. against the law, such abortion should be safe.” The Report In 1999, the UN Committee on the Elimination of All of the Fourth World Conference on Women, held in Forms of Discrimination Against Women (CEDAW) Beijing in 1995, noted “unsafe abortions threaten the lives determined that neglect of health services that only women of a large number of women, representing a grave public need is discriminatory and a defi cit that governments must health problem as it is primarily the poorest and youngest remedy. Furthermore, CEDAW noted that criminalisation who take the highest risk”.96 At the Special Session of the of abortion is a barrier that states should remove.100 www.thelancet.com Published online November 1, 2006 DOI:10.1016/S0140-6736(06)69481-6
In 2005, the UN Human Rights Committee ruled non-profi t reproductive health organisation focused on safe abortion and against Peru for its denial of a legal abortion; the woman women’s reproductive rights. Ipas manufactures and distributes manual had an anencephalic fetus and was forced to continue the vacuum aspiration instruments worldwide. SS is employed by the Guttmacher Institute, an organisation committed to improving sexual pregnancy to delivery.101 The Inter-American Commission health and rights, including improving access to safe and legal abortion on Human Rights ruled in favour of a 13-year-old Mexican services. FEO, MR, and BG are members of the steering committee of the girl’s petition; she had been raped and subsequently International Consortium for Medical Abortion, which aims at expanding access to medical abortion in the context of safe abortion worldwide. BG is denied access to a legally permitted abortion by state a full time salaried employee of Ipas and has never been a provider of abortion services. She has received fi nancial support for and been the result, the Mexican government will issue guidance for proncipal investigator on several several social science studies on maternal access to abortion for rape victims. Moreover, the health and unsafe abortion. FEO is the Executive Project Director of the International Federation of Obstetricians and Gynecologists and the government agreed to compensate the young woman and Honorary Adviser to the President of Nigeria on Maternal and Child her son for health care, education, and professional Health. He is a member of the Abortion Research Consortium in Africa, development. The 2005 Protocol to the African Charter on and a consultant to several international organisations on abortion matters Human and Peoples’ Rights on the Rights of Women in in Africa. Through the NGO which he founded in 1995, the Women’s Health and Action Research Centre, he has received funding specifi cally Africa is the fi rst international human rights instrument from the Lucile and David Packard Foundation to build capacity for safe abortion service delivery among private practitioners in northern Nigeria. He has received very modest honoraria for speaking on abortion in Africa Discussion
at several international fora. He receives a fi xed salary from the university, which is not dependent on his research on abortion. IHS is a social Unsafe abortion endangers health in the developing scientist with the Special Programme in Human Reproduction, and world, and merits the same dispassionate, scientifi c coordinator of the Programme’s Team on Preventing Unsafe Abortion. His approach to solutions as do other threats to public health. duties include supporting research on social science and operations Although the remedies are available and inexpensive, research in sexual and reproductive health, including users’ perspectives on family planning and adolescent and reproductive health. He has given governments in developing nations often do not have the lectures with no fi nancial renumeration from any source besides the fi xed political will to do what is right and necessary. The salary and associated benefi ts from WHO. All authors have no fi nancial benefi ciaries of access to safe, legal abortion on request stake in any abortion clinic, and own no individual stocks in any drug include not only women but also their children, families, company or medical supply house that might profi t from abortion. and society—for present and future generations. Acknowledgments
Women have always had abortions and will always We thank Elisabeth Åhman, Patty Skuster, and Barbara Crane. I Shah is a staff member of the World Health Organization. The author is continue to do so, irrespective of prevailing laws, responsible for the views expressed in this publication and they do not religious proscriptions, or social norms.104 Although the necessarily represent the decisions, policies, or views of the World Health ethical debate over abortion will continue, the public- health record is clear and incontrovertible: access to References
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