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AOFOG Book_Final

Authors:
  • Ipas Devt. Foundation India
Editors:
Dr. Rohana Hathtootuwa
Dr. Jaydeep Tank
Prevention of
Unsafe Abortion
in Asia Oceania Region
A Publication of the
Asia & Oceania Federation of Obstetrics & Gynecology
Reproductive Endocrinology Committee
Subcommittee on Unsafe Abortions
Design & Printed by : Impression Communications, +91 9810096529, atul.impcom@gmail.com
AOFOG COUNCIL MEMBERS
(from http://www.aofog.org accessed on 15th March 2009)
Professor Yoon-Seok Chang
President
KOREA
Professor Pak-Chung Ho
President Elect
HONG KONG
Professor Yuji Murata
Immediate Past President
Chairman, Scientific Programme
Committee, AOCOG 2009
JAPAN
Dr. C. Anandakumar
Vice-President
Chairman, Ultrasound Committee
SINGAPORE
Professor Yu-Shih Yang
Treasurer
TAIWAN
Professor W W Sumpaico
Secretary-General
PHILIPPINES
Dr. Kurian Joseph
Deputy Secretary-General
INDIA
Professor Takashi Okai
Chairman, Journal Committee
JAPAN
Professor Joo-Hyun Nam
Chairman, Endoscopy Committee
KOREA
Professor Tsuyomu Ikenoue
Chairman, Maternal & Perinatal Health
Care Committee
JAPAN
A/Prof Eng Hseon Tay
Chairman, Oncology Committee
Council Member
SINGAPORE
Professor A. B. Bhuiyan
Chairman, Population Dynamics
Committee
BANGLADESH
Dr. Rohana Haththotuwa
Chairman, Reproductive Endocrinology
Committee
SRI LANKA
Professor Tsung-Hsien Su
Chairman, Urogynecology Committee
TAIWAN
Dr. Peter Elliott
Chairman, Advisory Committee
Past President & Fellow
AUSTRALIA
Professor Suporn Koetsawang
Chairman, Fellowship Selection
Committee
Past President & Fellow
THAILAND
Dr. Jeffrey Tan
Liaison Officer
AUSTRALIA
Dr. Narendra Malhotra
Chairman, Newsletter, Publication and
YGAA
INDIA
Dr. Alec Ekeroma
Chairman of the Organizing Committee
XXI AOCOG 2009
NEW ZEALAND
A/Prof Rajat Gyaneshwar
Council Member
AUSTRALIA
Dr. Ferdousi Begum
Council Member
BANGLADESH
Professor M B Sammour
Council Member
EGYPT
Professor Hextan Ngan
Council Member (Hong Kong)
HONG KONG
Dr. Shyam Desai
Council Member (India)
INDIA
Dr. Suryono I. Santoso
Council Member (Indonesia)
INDONESIA
Professor Eliezer Shalev
Council Member (Israel)
ISRAEL
Prof. Toshiharu KAMURA
Council Member
JAPAN
Professor Young-Tak Kim, M.D.
Council Member
KOREA
Dr. Ravi Chandran
Council Member
MALAYSIA
Dr. Purevsuren Genden
Council Member
MONGOLIA
Professor Dr. Daw Than Than Tin
Council Member
MYANMAR
Dr. Pramila Pradhan
Council Member
NEPAL
Dr. Razia Korejo
Council Member
PAKISTAN
Dr. Ligo Augerea
Council Member
PAPUA NEW GUINEA
Dr. Rogelio P. Mendiola
Council Member
PHILIPPINES
Dr. Hesham Arab
Council Member
SAUDI ARABIA
Dr. Lakshmen Senanayake
Council Member
SRI LANKA
Professor Horng-Der Tsai
Council Member
TAIWAN
Professor Pratak O-Prasertsawat
Council Member
THAILAND
Professor Nguyen Duc Vy
Council Member
VIETNAM
President’s Message vii
Secretary General’s Message ix
Editors' Note xi
Acknowledgement xiii
Position statement on preventing unsafe abortions - the Tokyo declaration xv
Chapter-1
–Lakshman Senanayake, Sri Lanka
Chapter-2
–Anibal Faúndes and Melissa Upreti, Brazil
Chapter-3
–Duru Shah & Ashwini Bhalerao-Gandhi, India
Chapter-4
–Upul Senarath, Shyam Desai & Rohana Hathtootuwa, Sri Lanka and India
Chapter-5
–Malik Goonewardene, Sri Lanka
Chapter-6
–Rajat Gyaneshwar, Australia
Chapter-7
–P.C. Ho and E.H.Y. Ng, Hong Kong
Chapter-8
–Walfrido W. Sumpaico, Phillippines
Chapter-9
–Sushanta K. Banerjee & Jaydeep Tank, India
Chapter-10
–A Kurian Joseph, India
Prevention of Unsafe Abortion in the Asia Oceania Region 1
Preventing Unsafe Abortions: Global Solutions 17
Sexual and Reproductive Health and Women’s Rights in Context 33
Consequences of Unsafe Abortion 49
Preventing Unwanted Pregnancies and Reducing Induced Abortion 59
Preventing Unsafe Abortions: Post Abortion Care 67
Prevention of Unsafe Abortion: Technology Update 79
Role of Professional Organizations in Advocacy Programs 91
Expanding the Provider Base: Improving Access, Saving Lives 93
Moral, Ethical & Legal Aspects of Abortions 105
v
Maternal mortality is a serious concern for most countries of the
Asia Oceania region, with these countries having maternal
mortality rate higher than the UN Millennium Goals (MDG 5).
One of the key contributors to this high maternal mortality is
unsafe abortions. In the year 2000, there were 10.5 million
estimated unsafe abortions in Asia, which is more than half of
the 19 million estimated unsafe abortions occurring globally.
More than 50% of all maternal deaths due to unsafe abortion
globally, occur in the region.
Protecting women's health is one of the high priority areas for
AOFOG, and it strongly believes that to achieve the MDG 5 on
maternal health the issue of unsafe abortion and post abortion
complications in the region must be addressed. The laws in all
AOFOG member countries permit abortion on some grounds,
whether to save a woman's life, to preserve her physical or mental
health, in cases of rape and incest, for socio-economic reasons, or
on request. It was with this objective that the Federation adopted
the position statement on preventing unsafe abortions: The Tokyo
Declaration in 2007. The Federation is happy to note that all its
member associations have exhibited immense commitment
towards the issue and have been making attempts to address it
within the context of their own countries.
This publication on 'Preventing Unsafe Abortion in the Asia
Oceania Region' which is a combined effort of members from the
various country associations of the Federation is in continuation
to our efforts to address the issue of unsafe abortions it is a
comprehensive reference book for abortion services in the
region. AOFOG recognizes abortion services and abortion care
beyond its purely clinical aspects and has therefore also tried to
incorporate other dimensions of the issue into this compilation.
This includes addressing abortion from a social perspective, and
role of the various levels of providers and policy makers in making
safe abortion a reality for women of the region. We believe this will
be a useful means of sharing knowledge about the issue and
encouraging enabling action to increase access to safe abortions.
Prof Yoon Seok Chang
President AOFOG
Past Chairman of the Board, KSOG
Professor Emeritus, Seoul
National University, Seoul, Korea
Honorary Director,
Maria Fertility Hospital, Seoul
Prof Yoon Seok Chang March 2009
PRESIDENT’S MESSAGE
vii
SECRETARY GENERAL’S MESSAGE
Unsafe abortions account for a substantial number of deaths
and morbidities (pelvic infection, reproductive tract surgery
and infertility) among women in our federation. Certainly,
many factors both medical and non-medical can account for
such a dire situation.
AOFOG has dared to make an advocacy of Preventing Unsafe
Abortions. This document hopefully presents an unbiased
view of the approaches to this difficult problem.
I commend and conngratulate the AOFOG's Reproductive
Endocrinology Committee (Dr. Rohana Hathtootuwa, Chairman
and Dr. Jaydeep Tank, Steering Committee Chair) for
spearheading the discussions on various topics related to the
theme, the formulation of the consensus statements and
finally the publication of this document.
Walfrido W. Sumpaico, MD
ix
Walfrido W. Sumpaico, MD
AOFOG Secretary General
Professor, MCU-FDT Medical Foundation
Chairman, East Avenue Medical Center
President, United Doctors Medical Center
Honorary Fellow, Korean Society of
Obstetrics and Gynecology
Honorary Fellow, Taiwan Association of
Obstetrics and Gynecology.
EDITORS' NOTE
It is our privilege to edit this publication. We thank the AOFOG and the office
bearers for giving us this opportunity. We would also like to acknowledge the
tireless efforts of the Ipas India office for all their assistance and support.
That unsafe abortions claim an inordinate number of lives is undisputed.
What makes this fact even more tragic is that most of these deaths are
preventable by technology which is efficient, safe and available. The problem
seems to be getting it to where it is needed the most. Access to services and
awareness remains the biggest barrier for a large majority of women who put
their lives on the line to terminate an unwanted pregnancy.
This publication reiterates AOFOG's commitment to women's health and to
the cause of reducing the unacceptable maternal mortality and morbidity
from unsafe abortions
We would here like to acknowledge the efforts of all our contributors. They
have all done so willingly and with great thought and analysis of this
multidimensional problem. The readers will notice that there is, in fact, not
much uniformity in the format of the various articles. This was done
deliberately to allow the contributors free rein to express their views and also
reflect the concerns from their parts of the region specifically.
We are aware of our responsibility to bring to you an issue, which is timely,
informative, and finally inspiring. We hope we have succeeded.
xi
“It is the mark of an educated mind to be able to entertain a thought without accepting it.
–Aristotle
Dr. Rohana Hathtootuwa Dr. Jaydeep Tank
The development of this book was spearheaded by the Reproductive Endocrinology
Committee of AOFOG and the Sub-Committee on Unsafe Abortions. AOFOG and
both the committees are grateful to the contributors of this publication for their
support and commitment in developing the book. AOFOG acknowledges with
thanks the members of SAFOG and the core group who helped in drafting the
'Position Statement on Preventing Unsafe Abortions, The Tokyo Declaration' for their
commitment and cooperation in addressing the issue of unsafe abortions. The efforts
of Ipas in providing the logistic and financial support in producing this publication is
highly appreciated. The editors of this publication would like to acknowledge the
office bearers of the AOFOG for their guidance and encouragement in the
development of this publication.
ACKNOWLEDGEMENT
xiii
xv
xvi
xvii
REFERENCES
xviii
I
1
unsafe abortion is heavy. This region is
burdened with three negative health issues,
among many, which may be discussed here
as they have a direct relation with the topic
of unsafe abortion.
The estimated global tragedy of maternal
deaths for the year 2005 was 536,000. The
estimated number of deaths from Asia alone
amounted to 241,000 (44.9%) with a mere
895 (0.16 %) being the contribution from
(4) .
Oceania. South Asia contributed 188,000
deaths to this number. The significance of
the contribution of Asia to maternal death
burden was re-emphasized in the State of
(5)
the Children Report, 2009. (Chart 1)
Burden of Maternal Deaths
Introduction
Oceania comprises many small island
nations with a population of 10 million, while
Au s t ralia and N e w Z ealand have a
population of 25 million, along with a small
population of the Oceania part of Indonesia.
Asia, on the other hand, is the largest
continent on earth, covering nearly 9% of
the earth's surface. With a population of 4
billion, Asia is the home to nearly half of the
(1)
world's poor.
South Asia comprises India, Pakistan,
Bangladesh, Sri Lanka, Nepal, Bhutan,
Maldives, and British Indian Ocean Territory.
Some definitions of South Asia may include
Afghanistan, Myanmar, Tibet, and even Iran.
South Asia has a total population of 1.7
billion, with India alone contributing 1.1
billion.
Most of the countries in this region, other
than Japan, South Korea, Hong Kong
Singapore, Australia and New Zealand could
be considered as “Developing countries or
countries with “Developing and Emerging
(2) (3)
Economies”
For the purpose of this discussion comments
would be made mostly on information and
issues related to the member countries of
the Asia Oceania Federation considered as
developing countries where the burden of
Prevention of Unsafe Abortion in
the Asia Oceania Region
–Lakshmen Senanayake*
Maternal death, 2005
Rest of the world:
28,000 (5%)
Asia : 232,000
(43%)
Africa: 276,000
(51%)
Source: UNICEF global databases.
(5)
Source: State of the World's Children Report 2009
Chart 1
2
This favorable trend had been echoed by the
recently published State of the World's
(5)
Children Report 2009.
Even within “Developing Countries” of the
region, there is a marked variation in the
estimated maternal mortality rates. Some
examples are given below :
However, a comparison of the Maternal
Mortality estimates between 1990 and 2005
showed a remarkable improvement of the
MMR in the South Asian Region.There was a
reduction of 22% in Asia compared to a
reduction 5.4% of the global MMR The
progress is remarkable considering the fact
that the mean reduction of MMR for all
developing countries was only 6.3%.
Table1: Estimated Maternal Deaths
Country Number of Maternal deaths MMR Range of Uncertainty
Lower Estimate Upper Estimate
Afghanistan 26,000 1800 730 3200
Bangladesh 21,000 570 380 760
India 117,000 450 300 600
Maldives 12 120 42 260
Nepal 6500 830 290 1900
Pakistan 15,000 320 99 810
Vietnam 2500 150 40 510
Timor 190 380 150 700
Sri Lanka 190 58 39 78
Singapore 05 14 14 27
New Zealand 05 09 09 18
Japan 70 06 06 12
Australia 11 04 04 09
(4)
Source : Maternal Mortality Estimates WHO, UNFPA, UNICEF and World Bank 2005.
child marriages which has possibly a close
(5)
relation to unsafe abortion. Chart 2
Burden of Child Marriages
Another negative health behavior which has
a high prevalence in this region is the issue of
Chart 2.
* Excludes China. ** Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa.
Source : Demographic and Health Surveys, Multiple Indicator Cluster Surveys and other national surveys.
West/Central Africa
Child marriage is highly prevalent in South Asia and sub-Saharan Africa
Eastern/Southern Africa
South Asia
Middle East/North Africa
East Asia/Pacific*
Latin America/Caribbean
CEE/CIS
N/A
Sub-Saharan Africa**
Developing countires*
Least developed countries 49
36
40
11
19
18
49
36
44
Percentage of women aged 20-24 years who were married or in union before they were 18 years old, 1988-2007
0 10 20 30 40 50 60
3
provision of abortion services, even where
legally allowed, as well as post abortion care.
This results in a higher number of deaths due
to unsafe abortion.
Burden of Inadequate Resources
The developing countries of this region have
an additional burden of less government
spending on health, which hinders the
Chart 3.
WHO regions
The Americas
Europe
Africa
Eastern Mediterranean
South-East Asia
Western Pacific
Country groups
by income level
Global
High income
Upper middle income
Lower middle income
Low income 45
2
2
910
16 18
89
34
45
7
7
89
14 15
16 18
0 2 4 6 8 10 12 14 16 18 20
General government spending on health care as share of total government expenditure, 2005
2000
2005
Asia has among the lowest levels of government spending
on health care as a share of overall public expenditure
(5)
Source: State of the World's Children Report 2009.
Bureau, United Nations agencies, country
reports and specialized surveys carried out
by a variety of respectable research
( 7 )
organizations. This h i g h l i g h t s t h e
magnitude of the burden of abortion
contributing to maternal deaths.
Contribution of Unsafe Abortion to
High Maternal Mortality Rate in Asia
The Global Health Council has compiled a
country-by-countr y profile of all 227
countries in the world, based on the best
available statistics from the U.S. Census
(7)
Source: Promises to keep Global Health Council
Number of women aged 15 45 759,094,053
Pregnancies 108,017,572
Unintended pregnancies 29,836,174
Births 68,942,932
Unintended Births 6,764,124
Abortions (induced) 22,872,050
Deaths due to Abortions 30,907
All maternal deaths 205,733
Total deaths due to unintended pregnancies 51,695
Table 2: Estimated Number of Events in the year 2000 in Asia
abortion but the actual death rate per
abortion appears to be lower than in other
regions. On the other hand, Asia has a higher
maternal death rate when other causes
excluding unsafe abortion are considered.
Other authors have estimated lesser
numbers of abortions, as low as 10,500,000,
(9)
in Asia. When compared with other regions
of the Developing World, Asia seems to
contribute more in numbers of deaths due to
4
Percentage contribution made by Unsafe
Abortion to MMR in Sri Lanka.
A systematic review in 2006 which analyzed
information in 160 data bases identified the
contribution made by unsafe abortion as a
cause of maternal death which appears to be
(6)
different in different regions of the world.
Table 3
Abortion Rates in selected countries
(7)
Source: Promises to keep Global Health Council.
Maternal Deaths Death Rate per Maternal Death Rate
as a result of 100,000 excluding abortion
Abortion ('ooo) Abortions deaths per 100,000 LB
Asia 204 154 233
Africa 145.2 675 85.7
Latin America 27.4 94 173
Table 4
% of Maternal Deaths due
to abortion as the cause
Asia 5.7
Africa 3.9
Latin America 12.1
Source: WHO analysis of causes of maternal
(6)
death: a systematic review.
Source: Rgistrar Generals Department
(20)
Family Health Bureau
Contribution of unsafe abortion to maternal
mortality in different countries of the region,
too, is variable. Percentage of deaths due to
abortion in Pakistan has been quoted as 5.6
% in a national survey and much higher
(10) (11)
figure of 11% on a hospital based study.
Nepal in a study on a community based
study, showed that 5.4% of direct maternal
deaths were due to abortion. Direct deaths
amounted to 70% of maternal deaths in this
(17)
study.
India reported a rate of 12.6, Myanmar 38.4,
(18) (19)
Thailand 16.9, and Sri Lanka 9.8% In Sri
Lanka, although the total number of
maternal deaths and the number of
maternal deaths due to abortion have gone
down, the significance of abortion deaths
has come in to prominence.
In the yea r 20 0 6 , the pe r c e nt a ge
contribution of unsafe abortion was 11.6
and the second common cause of maternal
mortality although the total number of
(20)
deaths for the year was only 17.
Magnitude of the problem
Owing to the sensitive nature of the issue
and the restrictive laws prevalent in some of
the countries in the region, accurate data
sources are limited particularly for most of
the developing countries. The estimated
number of abortions in Asia, in 2003, was
25.9 million and there was a marginal
reduction between the years 1995 and 2003
which amounts to 58.7 % of all induced
abortions in the world. The change in the
rate of abortion given as abortions per 1000
women in the 15 to 44 years age group for
both Asia and Oceania was marginal.
Year Percentage contribution of
Unsafe Abortion
1930 0.8
1935 0.9
1940 1.6
1945 1.3
1950 1.5
1955 2.9
1960 2.7
1965 2.4
1970 6.2
1980 10.7
1985 11.2
1991 11.3
1995 4.4
2000 13.0
2005 13.9
Table 5
5
Table 6: Global and Regional Estimates of Induced Abortions 1995 and 2003
Abortion Rates in selected countries
Region No. Abortions in (million) Abortion Rate (per1000
Women aged 15-44 years)
1995 2003 1995 2003
Asia 26.8 25.9 33 29
Africa 5.0 5.6 33 29
Latin America 4.2 4.1 37 31
Oceania 0.1 0.1 22 21
World 45.6 41.6 35 29
(13) (14)
Source: Alan Guttmacher Institute
Within Asia, different regions show a widely
different estimated rates of abortion. The
lowest rate was seen in Western Asia which
was 29 while the highest rate was 34, in
(22)
South East Asia. Different countries within
the region too showed different rates of
abortion. Table 7 from one source is given
below.
However local research has estimated much
higher number of abortions in many
countries; for example, In Sri Lanka estimates
are as high as 175,000.
The distinction between safe and unsafe
abortions is crucial because each has
different public health implications. Safe
abortion has very few health consequences
where as unsafe abortions are a threat to
(23)
health and survival of women. The data on
unsafe abortion is difficult to get particularly
on a national level. Available data too may be
for different years for different countries.
In most countries where abortion is legal,
there is some mechanism for collecting data
on safe abortion. Even here, data may not be
100% complete. In one of the studies where
a detailed study was made and estimates
and trends world wide was done, a
correction factor of 1.4 on average, which
corresponds to an inflation of official
(22)
Source: Health in Asia and Pacific 2008.
Table 7: Abortion Rates in selected countries
Country Number of Abortions ('ooo) Abortion Rate per 1000 women
aged 15-49
Bangaldesh 389 12
Bhutan 10 23
Cambodia 129 49
India 5743 24
Indonesia 1939 35
Malasia 208 38
Mongolia 45 66
Myanmar 567 45
Nepal 116 21
Republic of Korea 458 35
Singapore 21 21
Sri Lanka 40 08
Thailand 223 13
Viet Nam 1183 57
6
world which accounts for 59% of the world's
abortions, is estimated to have 17 million
abortions of which 10 million would be
(25)
illegal and unsafe. Bangladesh and India
have low official rates of menstrual
regulation and abortion respectively but the
actual rates are much higher. An estimated
number for MRs performed by registered
practitioners is 468,000 which is almost four
times the reported number.
In India, the number of abortions performed
by physicians is estimated to be twice the
repo rt ed n u m b e r, and t h e numbe r
performed by non physicians is thought to
(25)
be several times higher. Recent estimate of
global abortions found that almost half of all
abortions performed in the world were
unsafe and in contrast to the rest of the
developing world more that half of the
(14)
abortions are estimated to be safe.
Abortion rate for Oceania was comparatively
low and mostly legal and safe.
Adolescents comprise 9% of all abortion
(27)
seekers in Asia. This is remarkably low
when compared with other regions of the
world. It is also paradoxical when one
recognises that child marriages are common
(5)
in Asia compared to other regions.
Characteristics of women who seek
abortions in different countries in the
region
estimates by 40%, was applied where
completeness was in doubt. In this study,
correction factor ranged from 1.05 for USA to
(23)
3.0 for Bangladesh.
Even in countries where abortions are
legalised only those which conform to the
legal requirements may be reported. This is
seen in Bangladesh where menstrual
regulation is legal and reported in official
statistic but the abortions are legally
(25)
restricted though common. Although
legally allowed, unsafe “illegal” abortions
may be done for many reasons such as lack of
access to available services as well as cost
and transport.
In countries with restrictive laws, data based
estimates are scarce as they require
extensive research. Such estimates may start
on statistics on women hospitalized for
ab ortion c ompl icat ions. I n a ddit ion,
community surveys and opinion surveys of
health professionals as well as confidential
research done among abortion seekers
provide supplementary information.
Demographic and Health surveys will not
capture the magnitude of unsafe abortion in
countries with restrictive laws. The DHSS in
Sri Lanka showed a downward trend and an
unbelievably low value where as many
estimates made on scientific basis showed a
(24)
high incidence of unsafe abortion.
In one of the early global estimates made in
1999, Asia, the most populous region in the
Table. 8
Country Number of Abortions (million) Abortion Rate
Total Safe Unsafe Total Safe Unsafe
Asia 25.9 16.2 9.2 29 18 11
Oceania 0.1 0.1 0.02 17 15 2
Africa 5.6 0.1 5.5 29 - 29
Latin America 4.1 0.2 3.9 31 01 29
World 41.6 21.9 19.7 29 15 14
(14)
Source: Induced Abortions: estimated rates and trends
This is reflected in the estimated case fatality rates of unsafe abortions: Source WHO
7
Nepal, exact figures for unsafe abortion are
not available but for the same age group,
unwanted births increased from about 2 per
cent amongst mothers below 20 years of age
to as high as 72 per cent amongst women
(30)
aged 40-44 years.
Two large studies done in Pakistan showed
that 96 % - 91% of the abortion seekers were
(28)
married. Sri Lankan studies showed a
similar pattern with 96% - 86% of abortion
(24)
seekers reporting to be married. A study
from India reported that 12% of the abortion
(29)
seekers were unmarried.
Marital Status
The highest rate of abortion is seen in the
age group 25-29 in Asia in contrast to the age
(9)
group of 20-24 in the other two regions.
Whe n on e co n s iders the indiv i dual
countries, an analysis of six studies showed
that below 19s contributed for 2.9 - 8.6 % of
(24)
abortion seekers in Sri Lanka. A situational
analysis conducted recently in Pakistan
found that only 3.3%-3.9% of women
(28)
undergoing abortion were 19 or less.
In contrast, a similar analysis of available
data in India showed a high percentage of
adolescents up to 10% and it was interesting
to note that half of unmarried women
(29)
seeking abortion were adolescents. In
Chart 4.
Source: Unsafe Abortion Global and Regional Estimates of the Incidence of Unsafe Abortion and
26
Associated Mortality WHO
Table. 9 : Age specific unsafe Abortion Rate (per 1000 women in the age group15-44)
Age Africa Asia Latin America &
Caribbean
15 19 24 8 20
20 24 37 24 43
25 29 28 33 41
30 34 21 29 28
35 39 16 19 21
40 44 6 12 14
(9)
Source: Abortion Law, Policy and Practice
8
Chart 5: Fertility planning by
birth order, Nepal
(30)
Source: Situational Analysis NASOG
(28)
Source: Situation Analysis Pakistan
Variable
(13)
Study 1
(n=-786)
percentage
(27)
Study 2
(n=306)
percentage
(3)
Study 3
(n=356)
(28)
Study 4
(n=322)
percentage
(41)
Study 5
(n=75)
percentage
(40)
Study 6
(n=210)
percentage
No schooling 2.7 2.3 1 4.0 11.2
Primary (Year 1-5) 9.4 5.9 9 17.7 69.8
Secondary (Year 6-9) 31.2 31.7 22 39.8
GCE O/L, A/L 53.9 58.5 67 38.5 28.2
Graduates 2.7 1.6 0.7
Table11
Parity
There exists a positive association between
parity and abortion. Proportion of women
reporting induced abortion increased from
9% with two living children to 54% with
(29)
three-four living children. In contrast in
Pakistan the rate jumped from 22% to 88%
after the fourth child and one of the hospital
based survey showed a surprising figure of
(28)
16% among the nulliparous women.
Nepal, too, reported a similar picture with
regard to the unintended pregnancies.
Literature from India and Pakistan tend to
show that there is a higher incidence of
unsafe abortion among the less literate
segments (table.10)
This contrasts with the situation in Sri Lanka
but it may reflect the literacy pattern of the
population ra the r than a significant
(24)
determinant.
In Sri Lanka, the “youngest being too small”
was the commonest reason given, while “has
completed the family” was the next common
reason accounting for more than 60%
women. Similar situation appears to prevail
in Pakistan where nearly 67% women gave
fa mily buil d ing pref erenc es whi c h
included both these causes.
Reasons for seeking abortion
Table.10
Education
No education 62.5
Literate 9.2
Primary or less 2.6
Middle or higher 25.6
(28)
Source: Situation Analysis Pakistan
9
(traditional birth attendants) and the non-
poo r go to more qua l ified docto r s
(13)
depending on their ability to pay. The
private sector includes private practitioners
and a few service outlets run by NGOs.
In Nepal, before the legalisation of abortion
services, Traditional Birth Attendants (TBAs)
were reported to be the primary source of
Who provide the abortion?
In Pakistan the recently done situation
analysis shows that the providers of abortion
services include all categories of health care
providers viz. doctors, nurses, midwives and
dais (traditional birth attendants, TBAs). The
majority of safe abortions are performed in
the private sector. The poor go to dais
Table. 12 : Sri Lanka
Reason
Percentage
(n=786)
(13)
Study 1
Percentage
(n=356)
(3)
Study 3
Percentage
(n=203)
(40)
Study 6
Youngest too small 28.3 27.3 32.5
Has completed the family 21.8 12.6 12.8
Economic & other difficulties 14.8 13.2 21.1
For foreign employment 10.5 14.6 12.8
Career (local job) 3.4 2.5
Children too old 7.7 - -
Unmarried 4.0 2.5 6.9
Not physically or mentally fit for another child - - 6.9
Recent rubella vaccination 2.2 Health -
Previous cesarean section 1.3 reasons
On medication for illness 0.8 7.1
Using contraception 0.5 - -
Result of rape 0.8 -
Other 8.2 18.5 3.5
Total 100 100 100
Table 13: Pakistan
Family building preference 908 67.4
Birth spacing 179 29.19
Family complete 520 15.16
"Unwanted pregnancy" 209 6.1
Socio-economic concerns 156 11.58
Financial constraints 126 19.39
Disruption of women employment 28 0.82
Husband an addict 2 0.06
Extra-marital pregnancy 81 6.01
Preg continuing after husband's death 6
Non-use/failure of contraception 156 11.58
Lack of its awareness 22 0.64
Poor access 5 0.14
Failure 129 3.76
Maternal illness/weakness 40 2.97
Total 1347
No. %
10
plastic pipes (with or without medicines)
placed inside the uterus and there were also
very few women who had developed
complications after they were given
Misoprostol along with MVA or Syntocinon
injection.
In clinics providing abortion services, all but
one of 32 employed MVA or D & C, in the year
1997 in which the study was carried out. In
the hospital-based studies, the most
frequently used method was surgical
intervention, usually by a dilatation and
(30)
curettage performed in 48.06% of women.
In Sri Lanka, where abortion is restricted, few
studies conducted on abortion seekers
revealed that MR as vacuum aspiration and
D/C to be the commonest among illegal
abortions.
However, in Sri Lanka, relative to the large
number of abortions estimated to be more
than 100,000 a year performed in the
country the total number of women dying
within a year is less than 20. This paradoxical
situation has been called by some authors as
“safe abortion in illegal context”. The easy
access to antibiotics, and to hospital care for
complications may be responsible for this
favourable situation. However, the recent
efforts by the state to prosecute the
providers may push the women to seek the
assistance of “quacks” and traditional
(24)
methods with worse outcomes.
abortion service providers for a significant
propor t i o n o f women i n the r ural
communities. In addition, self administered
local herbs were also reported. The actual
procedures adopted by untrained providers
were dangerous and barbaric. For instance,
women admitted in the hospitals for
m a na g eme nt o f ab or t i on re la te d
complication were found to have sticks
pasted with cow-dung or herbal mixtures
inserted inside the uterus, injection of
unknown medicines, insertion of rubber
ca t h et er d ip pe d i nt o uni d en ti fi e d
(30)
substances.
The post-legalization reduction in unsafe
abortion for the country is difficult to
measure in light of the lack of information or
records on induced abortion related
admissions at health institutions. The PAC
units of most of the government hospitals
do not separate out induced abortion cases
from spontaneous abortion cases. As a
result, the number of clients with unsafe
abortions seeking PAC services from these
hospitals cannot be ascertained.
However, the 2006 National Facility-based
Abortion Study of CREHPA showed that
nearly a sixth of the women had orally
co n sumed allo p athic and ayu r vedic
medicines (17%) while less than this
percentage had placed unknown herbal
substances in the uterus to cause abortion
(30)
(14%). Very few women had catheter or
Method Physician % Non-Physician %
Vacuum aspiration 62
D & C (Dilatation & Curettage) 54
Prostaglandins / Injectables -
Hormones/Drugs - -
Indigenous medicine - 17
Catheter - 33
Other objects - 67
Massage - 17
Table. 14 : Provider and method used for abortion
11
level hospitals but only in one fifth of
primary care facilities. Public health facilities
are automatically approved for MTP under
the Act.
From a global perspective, prevalence of
unsafe abortions remains the highest in the
82 countries with the most restrictive
legislation, going up to 23 unsafe abortions
per 1000 women aged 15 - 49 years. In
contrast, the 52 countries that allow
abortion on request have a median unsafe
abortion rate of as low as 2 per 1000 women
(16)
aged 15 -49.
Although the case fatality rate is determined
by many determinants of health care
provision the abortion rate remains highest
in the regions where abortion is legally
restricted. Even in the developed countries
the case fatality rate for unsafe abortion is 20
(26)
times higher than that of legal abortions.
The common belief that abortion rates go up
if and when abortion is legalised does not
appear to be true. Countries that liberalised
abortion laws such as South Africa and
Turkey did not have an increase in abortions.
In comparison, Netherlands which has
unrestricted access to abortion has one of
(26)
the lowest abortion rates in the world. The
abortion rate for the developed world where
Why unsafe abortion is a problem
even in countries where it is legally
permitted
In India, even though abortion was legalized
in 1972, illegal abortions are two to five times
commoner than the legal or safe abortions.
(29) Around 53% women tried to perform
abortion at home by self or with the help of
friends / relatives even before approaching a
provider. Majority (84%) of these women
had consumed some tablets to abort while
7 % h ad t ak e n s om e h om e m a de
(2 9)
concoction. In formal or uncert ifi ed
providers include untrained medical doctors
and nurses; auxiliary nurse midwives
(ANMs), ayurvedics, homeopaths, dais or
traditional birth attendants, family health
workers, vil lage health p rac tit ion ers,
pharmacy shopkeepers and village women.
It was interesting to note that 90% women
who faced post abortion complications also
reported visiting at least one health provider
apart from attempting abortion at home
before approaching a medical college or
district hospital. Providers who had been
approached for the first time ranged from a
chemist (47%), rural providers/quacks (7%),
and other hospital workers (7%) to trained
doctor at public hospital (8%) and private
clinics (17%).
In India, methods used for legal abortion are :
early medical abortion approved till 49 days,
Vacuum Aspiration EVA and MVA and
Dilatation and Curettage for the first
trimester abortions. These services are
available in the tertiary, teaching and district
Case Fatality Rate
(No of deaths for 100,000 unsafe abortions)
Asia 300
Oceania 300
Africa 650
Subsaharan Africa 750
Latin America 50
Developed Regions 10
World 300
(26)
Source: Unsafe Abortion Global and Regional estimates 2003 WHO
Table. 15
12
maternal mortality due to unsafe abortion.
Shah Committee appointed for the purpose
recommended legal ising abortion to
prevent wastage of women's health and
lives on both compassionate and medical
grounds. MTP Act was passed in 1971 and
enforced in 1972.It was amended to approve
(3 2 )
Mefepri ston e for me dical abortion.
“Despite more than 30 years of liberal
legalisation it is estimated that there are 4 to
6 million illegal abortions in India per year.
The proportion of illegal abortions was 2 to 5
(29)
times that of legal abortions.
The initial years from 1972 to 1986 after
legalisation showed only 8 - 10% increase in
the number of approved facilities and even
by 1997 two thirds of the facilities were
urban based clinics, reflecting the inequity in
(32)
rural vs urban access. Even by 1990, only
10% total abortions were reported from the
government facilities.
A multicentre facility study of 380 abortion
facilities of which 285 were private showed
that, on average there were four facilities
providing abortion to 100,000 with average
of 1.2 providers at each facility. The same
study revealed that, of the formal providers,
55% were gynaecologists with an average of
120 abortions a year amounting to 4.8
million abortions of which one third were in
(33)
the private sector.
The same assessment revealed that only
24% of the private abortion facilities were
certified, having obtained the certificate
within a month while 68% never tried to
obtain it as they were not keen to register or
be accountable to the authorities.
Inadequate public investment in abortion
services reflected in the fact that only 25% of
abortion facilities in the formal sector were
public with 87% of abortions done in the
private sector. The cost of an abortion in the
private sector, too, limited access to services
particularly for the less privileged groups
such as scheduled (dalits) and tribals
(adivasis). The experience in India possibly
reiterates the need for strengthening the
most countries have liberalised policies was
estimated to be 26 per 1000 women aged 15
- 49 for the year 2003 and that for developing
countries which includes mostly countries
(14)
with restrictive laws was 29.
A study on national laws and unsafe abortion
covering 165 countries showed that unsafe
abortion rate for countries with highly
restrictive laws was 24 for 1000 women of
reproductive age, but changed in countries
which allow abortion for fetal impairment
where the median unsafe abortion rate
dropped to 10 per 1000 women of the
reproductive age. The contrast becomes
more marked in the countries which allow
for economic or social reasons where it
drops to 0 - 2 per 1000 women of
(31)
reproductive age.
The same study revealed that maternal
mortality also follows the same pattern
coming down when the law changes to fetal
impairment, economic and social reasons.
This is possibly because most women opt for
an abortion for these reasons. The desired
favourable effect of making abortion legal is
shifting previously clandestine, stigmatised
and unsafe procedures to legal and safe ones
which are carried out easily and with dignity.
However, abortion being a very complex
social, medical and legal issue, simply
changing the law by itself does not seem to
work every where all the time. The additional
factors such as the availability of safe and
affordable services, knowledge of the
change in the law, as well as the rights of
women, and how empowered they are to
make use of these changes are some of the
determinants of the impact it is likely to
produce. In addition, the availability of
contraceptive services and the unmet need
of contr aception p artic ular ly to the
vulnerable groups such as the adolescents
and the young need to be a choice available
to the woman who desires to avoid the
pregnancy.
The process of liberalisation of abortion law
in India began in 1964 in the context of high
13
it has not been systematically evaluated and
(34)
its impact is not very clear. Maternal
mortality due to unsafe abortion is showing a
downward trend.
Until the law was changed in 2002, Nepal
had a very strict law on abortion which was
implemented very strictly. In 1997, a study
on female inmates of the jails found that
20% were women convicted for procuring
(36)
an abortion. 88% of the population live in
the rural areas and in many remote areas,
state health care presence is small and in
such situations they turn to traditional
healers for assistance. Literacy rates for
women are half that of men and the unmet
dema n d for contra c e p ti o n is high
(37)
estimated to be 59%.
It was a great achievement for Nepal to
become exceptionally liberal by allowing
abortion up to12 weeks for any woman with
her consent, up to 18 weeks if the pregnancy
is a result of rape or incest and at any time on
the advice of a medical practitioner if the
woman's life or mental and physical health is
at risk or the fetus is deformed or has a
condition not compatible with life. The
consent of the husband is not required if the
woman is over 16 years of age and for those
under16 the “guardian should consent who
could include any friend or family member.
(37) Abortion for sex selection and without the
consent of the woman became punishable
offences under this law.
Advocacy has started since 1980 and is
becoming increasingly forceful on a public
health perspective with a focus on reducing
maternal mortality, legal and human rights
issues. The strength on which advocacy
message were built on the premise that
…existing high level of maternal mortality
in the country is due to unsafe abortions…
and…maternal mortality levels can be
drastically reduced once women have access
(38)
to legal and safe abortions… In March
2002, six years after it was registered in the
parliament the Bill became an Act. This
le g al is a ti on has bro u gh t u p m a ny
(39 )
challenges, which are being faced
successfully by the government of Nepal.
commitment of the state and improvement
of the public sector services in order to
achieve the desired impact.
Bangladesh is unique in Asia in that although
abortion is prohibited except to save the life
of a woman, menstrual regulation is not
prohibited up to 6 to 10 weeks of a missed
period as it is considered to be an “interim
method to establish a s tate of non
pregnancy in a woman who is at risk of being
(35)
pregnant”. MR services are included in the
health services programme since 1978, and
included MR in the national family planning
programme and instructed all doctors and
paramedics to provide MR services in all
(35)
government hospitals.
Currently it is available in all tiers of health
facilities as well as in the limited number of
NGO clinics and in the private sector with
female paramedic providing the service at
the union level which is the lowest level
hospita l. R ece n t evaluation o f t he
programme found that at present there are
6500 family welfare visitors and 8000
doctors trained in MR who are posted in
government health facilities. At and below
the upazilla level, family welfare visitors are
the main providers of MR. They have had 18
months of training in family planning and
maternal and child health with additional
(35)
training in MR after their posting.
In addition a wide network of private
providers, existing as qualified practitioners
support the decentralised structure of the
programme extending to the grassroots level
and the fact that the state facilities provide the
major portion of service is unique and
international. Reproductive health and rights
experts have lauded the programme, though
14
place concurrently as service provision is
started.
Cost should be affordable to the poor
and preferably available free to the poor.
Sensitisation programmes should be
launched to minimise the stigma
attached to abortion which often is
considered as an “immoral and illegal
act”.
Monitor the outcomes to identify
negative outcomes such as abortion for
sex selection to take necessary steps to
prevent them.
Ensure a sustainable mechanism for post
abortion counselling and offering the
option of contraception.
An aggressive programme for reducing
the unmet need for contraception and
enhance the availability to prevent
abortion being converted to a method of
family planning.
Experience from many countries including
Rumania and South Africa show that
although liberalisation can certainly reduce
unsafe abortion and related maternal
mortality and morbidity, that alone is not
likely to succeed.
There is a need for continued advocacy to
sensitise and gain the assistance of
health care providers and other stake
holders such as legal fraternity.
Policies and procedural guidelines must
be si mple an d a dapt able to th e
circumstances available in the rural
context.
Ensure adequate service delivery points
particularly in the rural and geographically
unfavourable sites.
Service provision should not be confined
to consultants or medical officers but to
adequately trained health care providers
who should be held accountable
Clear mechanism and a programme for
training service providers must be in
Challenges for Implementation of the New Abortion Law in Nepal
1. Medical and Health related challenge
(a) Lack of adequate trained doctors and nurses and a high concentration of OB & GYNE
in few major cities
b) Lack of sufficient space equipment and clinicians at district hospitals and at lower
level facilities
(c) Limited hospitals equipped with MVA units and non specification about medical
abortions
(d) High % of “quacks
2. Socio-legal challenges
(a) Ignorance of rights and criteria for legal abortions
(b) Lack of clarity between spontaneous and induced abortions from the perspective of
accuser and the persecuter
(c) Possibility of falsely accusing the woman for terminating the pregnancy beyond the
gestational age
(d) Inadequacy of legal aid for women falsely accused for illegal abortion
(e) Negative social attitude for women seeking abortion
(f) Attempt for sex selective abortion
Source: CREHPA 2002(39)
15
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02. IMF Emerging and Developing Economies List. World Economic Outlook Database, April 2008.
http://www.imf.org/external/pubs/ft/weo/2008/01/weodata/groups.htm#oem
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04. Maternal mortality in 2005: Estimates developed by WHO, UNFPA and the World Bank. ISBN 978
92 4 159621 3 NLM Classification WQ 16
Published by World Health Organization
05. Maternal and New Born Health
State of the World's Children Report 2009
United Nations Children's Fund December 2008
ISBN 978 92 806 4318 3.
06. Khan KS et al. WHO analysis of causes of maternal death: a systematic review. Lancet, 2006,
367:10661074.
07. Promises to Keep Published by the Global Health Council with the support from Lucille and
Packard foundation 2002 www.globalhealth.org
08. Unsafe Abortions Facts and Figures 2006
Authored by Deborah Mesce and Erin Sines
Population Reference Bureau www.prb.org
09. Iqbal Shah, Elizebeth Ahmen
Age pattern of Unsafe Abortion in Developing Country Regions
Abortion Law, Policy and Practice in Transition
Reproductive Health Matters Vol. 12 Number 24 Suppl. November 2004
10. Pakistan Demographic and Health Survey, 2006-07, June 2008
National Institute of Population Studies (NIPS) and MEASURE DHS Macro International 2007
11. Jafarey SN: Maternal Mortality in Pakistan - An Overview in Maternal and Prenatal Health in
Pakistan. Proceedings of an Asia and Oceania Federation of Obstetric and Gynaecology (AOFOG)
Workshop, Karachi, November 1991. TWEL Publisher, Karachi 1992
12. Health in Asia and Pacific Chapter 6 Reproductive Health, child, adolescent health, Nutrition, and
health for older persons
13. Facts on Induced Abortion Worldwide October 2008 Guttmacher Institute
http://www.guttmacher.org/pubs/fb_IAW.html
14. Induced Abortion: estimated rates and trends worldwide Gilda Singh, Stanley Henshaw,
Susheela Singh, Elizebeth Ahmen,Iqbal H Shah
Lancet; 2007, 370:1338-45 WHO Guttmacher Instutute
15. Sedgh G et al., Women with an unmet need for contraception in developing countries and their
reasons for not using a method, Occasional Report, New York: Guttmacher Institute, 2007, No. 37.
16. Unsafe Abortion the preventable pandemic David a Grimes, Jenny Bensan, Sushila Singh,
Mariana Romero, Bela ganatra, Friday E Oknofua, Iqbal A Shah
Lancet2006; 368, 1908-1919
17. State of the Worlds Newborns: Nepal Saving Newborns July 2002 Save the Children US and His
Majesty's Government of Nepal.
http://www.savethechildren.org
18. Making pregnancy safer in South-East Asia Dr N kumara Rai, Dr Samu Mayan dali Regional Health
Forum WHO South east Asia region (Volume 6 Number1)
19. Trends in maternal mortality in Sri Lanka 2001-2005 published by Family Health bureau Ministry
of Health care and Nutrition 2009 (In print)
20. Maternal mortality Decline. The Sri Lankan Experience Family Health Bureau of the Ministry of
Health, Nutrition & Welfare UNICEF December 2003
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21. Information submitted at Maternal Mortality Review 2009
Family Health Bureau Ministry of Health care and Nutrition
22. Health in Asia and Pacific
Chapter 6 Reproductive Health, child, adolescent health, Nutrition and health for older persons
New Delhi: WHO Regional Office for South-East Asia ISBN 978-92-9022-333-7
23. Sedge G et al. Induced Abortion: Estimated Rates and Trends worldwide
Lancet 2007; 370:1338-45
24. Lakshmen Senanayake and Shreen Wilathgamuwa
Reducing the burden of Unsafe Abortion in sri Lanka Joint Publication of Sri Lanka College of
Obstetrician and Family Planning association of Sri lanka
ISBN 978 955 9179 03 0
25. Stanley K Henshaw, Susheela Singh and Taylor Hans. The Incidence of Abortion Worldwide Vol. 25
Supplement January 1999
International Family Planning Perspectives 1999, 25 (Supplement) S30-S38
26. Unsafe Abortion Global and Regional estimates of the incidence of unsafe abortion and
associated mortality 5th Edition WHO 2003
ISBN 978 92 4 1596 12 1
27. Ganantra Bela Young and Vulnerable Arrows for Change Vol.12 No3 2006
28. UNSAFE ABORTIONS IN PAKISTAN: A SITUATION ANALYSIS
Shahida Zaidi1, Azra Ahsan, Sadiqua N Jafarey and Imtiaz Kamal
Published by Society of Obstetricians and Gynaecologists of Pakistan,
National Committee for Maternal and Neonatal Health and Midwifery Association of Pakistan
29. UNSAFE ABORTIONS AND COMPLICATIONS A Situational Analysis 2008
India Working Group: Cehat, FOGSI, FPAI, Ipas, Lawyers' Collective, SoMI, UNFPAFIGOIPPF Iniative
on unsafe Abortion.
30. Situational Analysis of Unsafe Abortion in Nepal
Nepal Society of Obstetricians and Gynaecologists (NESOG)
August, 2008 UNFPA FIGO IPPF Iniative on unsafe Abortion
31. Marge Berger National laws and Unsafe Abortion: The parameters for change Global Perspectives
Reproductive Health Matters Volume 12. Number 24 Suppl. November 2004
32. Siddhiviniyak S Hirve Abortion Law, Policy and services in India: A Critical review Reproductive
Health Matters Volume 12. Number 24 Suppl. November 2004 p114-121
33. Ravi Duggal Vimala Ramachandran The Abortion Assesment Project India key findings and
recommendations Reproductive Health Matters Volume 12. Number 24 Suppl. November 2004
p 122 -129
34. Improved Maternal Health MDG 5 ICDDR, B Annual report 2007 p 6-7
www.icddrb.org/images/Ar2007_mdg-5.pdf
35. Seyda Nahid Mukith Chowdrey, Dipu Moni A Situation Analysis of the Menstrual regulation
Programme in Bangladesh
Reproductive Health Matters Volume 12.Number 24 Suppl. November 2004 p 95-103
36. Tamang AK Puri M NepalB et al Women in Prison in Nepal for Abortion Kathmandu Center for
Reproductive law Policy and CREPHA 2000
37. Ganga Shakya, Sabitri Kishore, Cherry Bird, Jennifer Barak Abortion law reform in Nepal : Women's
right to Life and Health Reproductive Health Matters Volume 12.Number 24 Suppl. November
2004 p 75-84
38. Saving women lives post legalization challenges and initiatives to ensure access to safe abortions
in Nepal. Reproductive Health research Policy Brief No.4.April 2002 www.crehpa.org.np
*Past President SLCOG
interrupt her studies and that a pregnant
woman will not lose her job, and will not
have to make a choice between continuing
her career or breastfeeding and taking care
of her baby.
As long as contraception is not 100%
effective and women do not have total
control over their sexual lives, there will
always be unplanned pregnancies and,
consequently, induced abortions. Such
abortions can be performed in safe or unsafe
conditions, depending mostly on the society
where the woman lives. Women's status in
society, legal situation of abortion, how the
law is interpreted, access to safe abortion
and the quality of post-abortion care, are the
main factors that will determine how safe or
unsafe is the pregnancy termination.
A number of international declarations,
resolutions and initiatives, viz. the 1994 Cairo
Conference on Population and Development
Programme of Actions; the 1995 Beijing
Conference for Women; the Millennium
Development Goals; United Nations General
Assembly Declarations; AOFOG Tokyo
Declaration; the Plans of actions of the
countries that participate in the FIGO
Initiative for the Prevention of Unsafe
Abortion, support all interventions to
reduce the number of induced abortions
and make the remaining abortions safe.
Abstract
Abortion laws in some countries of South
Asia are among the most restrictive in the
world. India and Nepal are the only two
countries in the region that have introduced
liberal abortion legislation. While every
induced abortion is the result of an
unintended pregnancy, all unplanned/
unwanted pregnancies may be the result of
imposed unprotected sex, for example,
limited knowledge and difficult access to
contraception; and lack of social support to
the pregnant women and mothers of young
children.
Currently, there is sufficient global
experience on the most efficient ways to
prov ide information a nd a ccess to
contra cep t io n . Sex educat ion m ay
encourage adolescents to postpone the
initiation of sexual activity and thus reduce
the number of adolescents who indulge in
sexual activity, getting pregnant and resort
to abortions. Countries with the lowest
abortion rates are those that have broad-
based, progressive sex education programs
in their schools and nearly universal school
attendance. Also, many women might have
continued their pregnancies if they had
more support from their families and from
society in general. Society must ensure that a
pregnant adolescent does not have to
II
17
Preventing Unsafe Abortions:
Global Solutions
– Anibal Faúndes* and Melissa Upreti**
the woman i s “of u n sound mental
6
condition” .
Abortion is generally prohibited by law and
permitted only to save the life of a woman or
7
to provide “necessary treatment” . The latter
is viewed as allowing abortion to preserve a
8
woman's physical or mental health
although formal regulations explaining the
9
application of this provision are lacking .
Abortion is further addressed through the
National Reproductive Health Services
Package which includes provisions for post-
10
abortion care . It includes specific goals for
raising awareness about the dangers of
unsafe abortion, promoting the detection
and early management of complications
and for counseling after an abortion which
includes information about family planning
10
methods .
The legal framework for abortion can be
11
found in the Penal Code, 1883 . Abortion is
11
permitted only to save a woman's life .
Punishments for illegal abortion include
fines and/or imprisonment for up to 20
11
years .
In 1973, a medical committee recommended
reforms permitting abortions where there is
a risk of injury to a woman's physical or
mental health, when the pregnancy is a
result of rape or incest and in cases where
12
there is a risk of foetal impairment .
However, no reform has taken place.
Abortion is generally prohibited by law but
permitted on several grounds, viz. to save the
life of a woman; to preserve the physical or
mental health of the woman; if the pregnancy
is a result of rape or incest; on indication of
foetal impairment; and upon request by a
Pakistan
Sri Lanka
Countries with liberal laws
Nepal
The legality of abortion in different
countries in the South Asian Region
The legal framework
Countries with restrictive laws
Afghanistan
Bangladesh
Bhutan
South Asia accounts for some of the most
restrictive abortion laws in the world. Most
countries in the region regulate the
procedure through their penal code. India is
the first country in the region that has
adopted abortion legislation, while Nepal
has recently introduced major amendments
which have transformed it from being the
country with the most restrictive laws to one
with the most liberal legislation.
The following section provides an outline of
abortion laws in seven countries in the
region: Afghanistan, Bhutan, Bangladesh,
India, Nepal, Pakistan and Sri Lanka. The
countries have been arranged as per the
level of restrictions on the procedure.
The Penal Code of Afghanistan permits
1
abortion to save a woman's life . However,
there are reports that the administration in
Kabul has legalized abortion till the third
2
month of pregnancy .
Abortion is permitted only to save a
3
woman's life . For an abortion to be
considered legal, it must be performed by
4
qualified physicians and in a hospital .
The government has officially sanctioned
menstrual regulation which is often used as
an alternative to abortion in the first
5
trimester of a pregnancy . Menstrual
regulation is performed without confirming
a pregnancy. Hence, it does not strictly
amount to termination of pregnancy.
Abortion is regulated by the Penal Code and
permitted to save the life of a woman if the
pregnancy is a result of rape or incest; and if
18
notable cause of maternal mortality in the
region. Unsafe abortion is believed to
20
account for up to 17% of maternal deaths in
India, higher than the global average of
21
13% . In Nepal, prior to law reform, it was
estimated that up to 50% of all maternal
22
deaths were due to unsafe abortion . The
situation in countries with more restrictive
laws is presumably worse. However, the
illegality of abortion makes it hard to
determine the real extent of the impact of
restrictions since abortions are usually
performed clandestinely.
Legalization does not automatically
guarantee the efficacy and safety of abortion
procedures. This is revealed by the situation
in India where despite the fact that abortion
has been legal for over 30 years, according to
government estimates, anywhere between
four to six million abortions are performed
23
illegally each year . This adverse trend may
be attributed in large part to factors such as
the prohibitive cost of the procedure, lack of
information about the availability of services
and poor knowledge about the legality of
24
abortion among women .
A low contraceptive prevalence rate has
further contributed to the high incidence of
unsafe abortion in the region. The
per ce nt ag e of m ar ri ed w om en o f
rep roductive age w ho use m o dern
25
contraceptives ranges from 20% in Pakistan
25
to 44% in Sri Lanka . Reliable data relating
to the use of contraceptives among
unmarried men and women, particularly
adolescents is absent. However, the fact that
up to 50% of all maternal deaths among
adolescents are attributable to unsafe
26
abortion demonstrates clearly that they are
a vulnerable group.
Key determinants of safe abortion include
the level of political commitment to
protecting and advancing women's health
as reflected in investments made by the
government in health infrastructure,
training of providers and the provision of
necessary medical equipment and supplies.
Many of these aspects are lacking in the
woman, within the first twelve weeks of
13
pregnancy . Abortion for the purpose of sex
13
selection is prohibited by law .
The Safe Abortion Services Directive, 2003,
co nt ai n s de ta il ed pr ov isi on s f or
implementing the law. Among other things,
it c ont ain s a r equ irem ent for the
involvement of a third party (a guardian,
relative or close friend) if the abortion is
14
sought by a minor .
Abortion has been legalized on broad
grounds through the enactment of the
Medical Termination of Pregnancy Act,
15
1971 . The procedure is permitted in cases
where the pregnancy poses a “risk to the life
15
of the pregnant woman or of “grave injury
15
to her physical or mental health” . Abortion
is also permitted in cases where there is a
“substantial risk that if the child were born, it
would suffer from such physical or mental
15
abnormalities to be seriously handicapped.
Abortion is further permitted in cases where
the pregnancy is a result of rape or of
contraceptive failure where the contraceptive
was used by a married couple “for the
purpose of limiting the number of
15
children” .
Abortions on these grounds are considered
legal only if performed in a registered
medical facility and by one or more
registered medical practitioners, depending
16
upon the gestation of the pregnancy .
The detection of foetal sex for the purpose of
performing a sex-selective abortion is
prohibited by the Pre-Natal Diagnostic
17
Techniques Act. Clinics that advertise or
promote sex-selective abortion are also
18
liable to be punished .
South Asia accounts for one third of unsafe
19
abortions in the world and the highest
number of