Unsafe Abortion: Unnecessary Maternal Mortality

Abstract

Every year, worldwide, about 42 million women with unintended pregnancies choose abortion, and nearly half of these procedures, 20 million, are unsafe. Some 68,000 women die of unsafe abortion annually, making it one of the leading causes of maternal mortality (13%). Of the women who survive unsafe abortion, 5 million will suffer long-term health complications. Unsafe abortion is thus a pressing issue. Both of the primary methods for preventing unsafe abortion-less restrictive abortion laws and greater contraceptive use-face social, religious, and political obstacles, particularly in developing nations, where most unsafe abortions (97%) occur. Even where these obstacles are overcome, women and health care providers need to be educated about contraception and the availability of legal and safe abortion, and women need better access to safe abortion and postabortion services. Otherwise, desperate women, facing the financial burdens and social stigma of unintended pregnancy and believing they have no other option, will continue to risk their lives by undergoing unsafe abortions.

Full text

122 VOL. 2 NO. 2 2009 REVIEWS IN OBSTETRICS & GYNECOLOGY
WOMEN’SHEALTH IN THE DEVELOPING WORLD
Unsafe Abortion: Unnecessary
Maternal Mortality
Lisa B. Haddad, MD, MA,* Nawal M. Nour, MD, MPH†
*Clinical Fellow in Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital,
Boston, MA; †Department of Maternal-Fetal Medicine, Brigham and Women’s Hospital, Harvard Medical
School, Boston, MA
Every year, worldwide, about 42 million women with unintended pregnancies
choose abortion, and nearly half of these procedures, 20 million, are unsafe.
Some 68,000 women die of unsafe abortion annually, making it one of the
leading causes of maternal mortality (13%). Of the women who survive un-
safe abortion, 5 million will suffer long-term health complications. Unsafe
abortion is thus a pressing issue. Both of the primary methods for preventing
unsafe abortion—less restrictive abortion laws and greater contraceptive
use—face social, religious, and political obstacles, particularly in developing
nations, where most unsafe abortions (97%) occur. Even where these obsta-
cles are overcome, women and health care providers need to be educated
about contraception and the availability of legal and safe abortion, and
women need better access to safe abortion and postabortion services. Other-
wise, desperate women, facing the financial burdens and social stigma of
unintended pregnancy and believing they have no other option, will continue
to risk their lives by undergoing unsafe abortions.
[Rev Obstet Gynecol. 2009;2(2):122-126]
© 2009 MedReviews®, LLC
Key words: Unsafe abortions • Maternal mortality • Postabortion care
According to the World Health Organization (WHO), every 8 minutes a
woman in a developing nation will die of complications arising from
an unsafe abortion. An unsafe abortion is defined as “a procedure for
terminating an unintended pregnancy carried out either by persons lacking the
necessary skills or in an environment that does not conform to minimal medical
standards, or both.”1The fifth United Nations Millennium Development Goal
recommends a 75% reduction in maternal mortality by 2015. WHO deems unsafe
abortion one of the easiest preventable causes of maternal mortality and a stag-
gering public health issue.
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Unsafe Abortion
VOL. 2 NO. 2 2009 REVIEWS IN OBSTETRICS & GYNECOLOGY 123
Scope of the Problem
Obtaining accurate data for abortions
is challenging, and especially so for
unsafe abortion. Two-thirds of na-
tions do not have the capacity to col-
lect data, and data collection varies
from country to country in both
quantity and quality.2Because unsafe
abortion is often done clandestinely
by untrained individuals or by the
pregnant women themselves, much of
it goes undocumented; figures are
therefore estimates. Data suggest that
even as the overall abortion rate has
declined, the proportion of unsafe
abortion is on the rise, especially in
developing nations. From 1995 to
2003, the overall number of abortions
declined, but the unsafe abortion rate
was steady (from 15 to 14 abortions
per 1000 women, respectively), con-
stituting an increase from 44% to
48%.3
In Western nations, only 3% of
abortions are unsafe, whereas in de-
veloping nations 55% are unsafe. The
highest incidences of abortions that
are unsafe occur in Latin America,
Africa, and South East Asia (Figure 1).
Methods
Even safe abortion in developing na-
tions carries risks that depend on the
health facility, the skill of the
provider, and the gestational age of
the fetus. With unsafe abortion, the
additional risks of maternal morbidity
and mortality depend on what
method of abortion is used, as well as
on women’s readiness to seek
postabortion care, the quality of the
facility they reach, and the qualifica-
tions (and tolerance) of the health
provider. Methods of unsafe abortion
include drinking toxic fluids such as
turpentine, bleach, or drinkable con-
coctions mixed with livestock manure.
Other methods involve inflicting di-
rect injury to the vagina or else-
where—for example, inserting herbal
preparations into the vagina or
cervix; placing a foreign body such as
a twig, coat hanger, or chicken bone
into the uterus; or placing inappropri-
ate medication into the vagina or rec-
tum. Unskilled providers also improp-
erly perform dilation and curettage in
unhygienic settings, causing uterine
perforations and infections. Methods
of external injury are also used, such
as jumping from the top of stairs or a
roof, or inflicting blunt trauma to the
abdomen.1,4
Health Consequences
Worldwide, some 5 million women
are hospitalized each year for treat-
ment of abortion-related complica-
tions such as hemorrhage and sepsis,
and abortion-related deaths leave
220,000 children motherless.4,5 The
main causes of death from unsafe
abortion are hemorrhage, infection,
sepsis, genital trauma, and necrotic
bowel.1Data on nonfatal long-term
health complications are poor, but
those documented include poor
wound healing, infertility, conse-
quences of internal organ injury (uri-
nary and stool incontinence from
vesicovaginal or rectovaginal fistu-
las), and bowel resections. Other un-
measurable consequences of unsafe
abortion include loss of productivity
and psychologic damage.
The burden of unsafe abortion lies
not only with the women and fami-
lies, but also with the public health
system. Every woman admitted for
emergency postabortion care may
require blood products, antibiotics,
oxytocics, anesthesia, operating
rooms, and surgical specialists. The
financial and logistic impact of
emergency care can overwhelm a
health system and can prevent
Data suggest that even as the overall abortion rate has declined, the pro-
portion of unsafe abortion is on the rise, especially in developing nations.
Unsafe abortions
to 100 live births
30 or more
20–29
10–19
1–9
None/negligible
Figure 1. Unsafe abortion: global and regional estimates of incidence of unsafe abortion and associated mortality
in 2003. Reproduced with the permission from the World Health Organization.1
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attention to be administered to other
patients.
Relationship With
Abortion Law
Abortion laws have a spectrum of
restrictiveness. Nations may allow
abortions based on saving the
mother’s life, preserving physical
and mental health, and socioeco-
nomic grounds, or may be com-
pletely unrestrictive (Figure 2). Data
indicate an association between
unsafe abortion and restrictive
abortion laws. The median rate of
unsafe abortions in the 82 countries
with the most restrictive abortion
laws is up to 23 of 1000 women
compared with 2 of 1000 in nations
that allow abortions.4Abortion-
related deaths are more frequent in
countries with more restrictive abor-
tion laws (34 deaths per 100,000
childbirths) than in countries with
less restrictive laws (1 or fewer per
100,000 childbirths).1
The same correlation appears when
a given country tightens or relaxes its
abortion law. In Romania, for exam-
ple, where abortion was available
upon request until 1966, the abortion
mortality ratio was 20 per 100,000
live births in 1960. New legal restric-
tions were imposed in 1966, and by
1989 the ratio reached 148 deaths per
100,000 live births. The restrictions
were reversed in 1989, and within a
year the ratio dropped to 68 of
100,000 live births; by 2002 it was as
low as 9 deaths per 100,000 births
(Figure 3). Similarly, in South Africa,
after abortion became legal and avail-
able on request in 1997, abortion-
related infection decreased by 52%,
and the abortion mortality ratio from
1998 to 2001 dropped by 91% from
its 1994 level.6
Less restrictive abortion laws do
not appear to entail more abortions
overall. The world’s lowest abortion
rates are in Europe, where abortion is
legal and widely available but con-
traceptive use is high; in Belgium,
Germany, and the Netherlands, the
rate is below 10 per 1000 women aged
15 to 44 years. In contrast, in Africa,
Latin America, and the Caribbean,
where abortion laws are the most
restrictive and contraceptive use is
lower, the rates range from the mid-
20s to 39 per 1000 women.3
Unsafe Abortion continued
124 VOL. 2 NO. 2 2009 REVIEWS IN OBSTETRICS & GYNECOLOGY
DEMOCRATIC PEOPLE’S
REPUBLIC OF KOREA
JAPAN
REP. OF KOREA
PALAU
TIMOR-LESTE
SOLOMON ISLANDS
VANUATU
NEW CALEDONIA
NEW ZEALAND
PHILIPPINES
MICRONESIA
KIRIBATI
NAURU
TUVALU
MARSHALL ISLANDS
BANGLADESH
VIETNAM
SRI LANKA
CHINA
MONGOLIA
RUSSIAN
FEDERATION
MALAYSIA
INDONESIA
HONG KONG
AUSTRALIA
FIJI
LAOS
BHUTAN
NEPAL
INDIA
MYANMAR
BRUNEI
PAKISTAN
AFGHANISTAN
KYRGYZSTAN
TAJIKISTAN
TURKMENISTAN
UZBEKISTAN
GEORGIA
ARMENIA AZERBAIJAN
QATAR
BAHRAIN
SOMALIA
SEYCHELLES
MALDIVES
DJIBOUTI
CYPRUS
TUNISIA
PORTUGAL
IRELAND
DOM. REP.
PUERTO RICO
ST. KITTS&NEVIS
ST. LUCIA
BARBADOS
TRINIDAD&TOBAGO
DOMINICA
ANTIGUA&BARBUDA
HAITI
TONGA
SAMOA
CUBA
BAHAMAS
ECUADOR
CHILE
GUYANA
FRENCH GUIANA
JAMAICA
BELIZE
GUATEMALA
EL SALVADOR
COSTA RICA
PANAMA
NICARAGUA
HONDURAS
ICELAND
GREAT
BRITAIN
DENMARK
NORTHERN
IRELAND
FRANCE SWITZ.
ITALY
AUSTRIA
LIECHTENSTEIN
SPAIN
ALBANIA
SAN
MARINO
MONACO
LEBANON
ISRAEL
LIBERIA
EQUATORIAL GUINEA
SAO TOME & PRINCIPE
ERITREA
SIERRA LEONE
GUINEA-BISSAU
GAMBIA
CAPE VERDE
WESTERN
SAHARA
WEST BANK/GAZA STRIP IRAN
U.A.E.
YEMEN
OMAN
CHAD
CAMEROON
GABON
CONGO
(BRAZZAVILLE)
SOUTH AFRICA
ANGOLA
NAMIBIA
BOTSWANA
ZIMBABWE
MALAWI
ZAMBIA
MOZAMBIQUE
LESOTHO
SWAZILAND
TANZANIA
DEMOCRATIC
REPUBLIC OF
CONGO
CENTRAL AFRICAN
REPUBLIC
NIGER
NIGERIA
BENIN
GHANA
COTE
D’IVOIRE
EGYPT
SUDAN
UGANDA
ETHIOPIA
MADAGASCAR
KENYA
BURUNDI
RWANDA
MALI
GUINEA
SENEGAL
ALGERIA
MAURITANIA
BRAZIL
BOLIVIA
PERU
PARAGUAY
ARGENTINA
URUGUAY
COLOMBIA
MEXICO
U.S.A.
CANADA
VENEZUELA
BURKINA
FASO
LIBYA
PAPUA
NEW GUINEA
CAMBODIA
KAZAKHSTAN
TURKEY
POLAND
GERMANY
BELGIUM
NETH.
SWEDEN
GREENLAND
NORWAY
FINLAND
CZECH
REP.
BELARUS
LITHUANIA
LATVIA
ESTONIA
UKRAINE
ROMANIA
SLOVENIA
BULGARIA
F.Y.R. MACEDONIA
HUNGARY MOLDOVA
SLOVAK REP.
SYRIA
JORDAN
IRAQ
KUWAIT
SAUDI ARABIA
THAILAND
TAIWAN
MOROCCO
GREECE
COMOROS
MAYOTTE
REUNIONMAURITIUS
FALKLAND ISLANDS
SOUTH GEORGIA
AND THE SANDWICH ISLANDS
TOGO
LUX.
SURINAME
SVALBARD
GRENADA
ST. VINCENT & GRENADINES
MALTA
SINGAPORE
ANDORRA SERBIA
MONTENEGRO
BOSNIA
HERZ.
CROA TIA
I
II
TO SAVE THE WOMAN’S LIFE OR
PROHIBITED ALTOGETHER
TO PRESERVE PHYSICAL HEALTH
III
IV
TO PRESERVE MENTAL HEALTH
SOCIOECONOMIC GROUNDS
VWITHOUT RESTRICTION
AS TO REASON
Figure 2. World abortion laws. Reproduced with permission from the Center for Reproductive Rights.
Less restrictive abortion laws do not appear to entail more abortions overall.
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Unsafe Abortion
VOL. 2 NO. 2 2009 REVIEWS IN OBSTETRICS & GYNECOLOGY 125
occur among women who were
not using any method of contracep-
tion.9Greater contraceptive access
and use alone can thus drastically
reduce safe and unsafe abortion by
reducing unintended pregnancies.
In the Russian Federation, abortion
rates sharply declined with the
advent of modern contraceptive
technologies.10
Obstacles to increased contracep-
tive access and use include religious
objections, lack of awareness of the
availability of contraceptive methods,
concerns about possible health risks
and side effects, and the mistaken
belief that one cannot or will not be-
come pregnant. Contraceptive use
must also be regular to be effective:
the average woman must use some
form of effective contraception for at
least 16 years to limit her family to
4 children, and for 20 years to limit it
to 2 children.11
What Needs to Be Done?
Although daunting, the predicament
is not without solutions. Preventing
unintended pregnancy should be a
priority for all nations. Educating
women regarding their reproductive
health should be incorporated in
schools. In nations that are not op-
posed to contraceptive use, increasing
contraceptive services is necessary;
this includes providing accurate in-
formation choices and proper use of
contraceptive methods. Governments
and nongovernmental organizations
need to find effective ways to over-
come cultural and social misconcep-
tions that restrict women from receiv-
ing necessary health care.
In nations where abortion is legal,
providing women better access to
health centers that perform abor-
tions is imperative. Practitioners
need to become better trained in
safer abortion methods and be able
to transfer patients to a medical
facility that is capable of providing
emergency care when a complication
arises. WHO strongly advises that all
health facilities that treat women
with incomplete abortions have the
appropriate equipment and trained
staff needed to ensure that care is
consistently available and provided
at a reasonable cost. In addition,
postabortion family planning coun-
seling needs to be an integral part of
the service.
Evidence demonstrates that liberal-
izing abortion laws to allow services
to be provided openly by skilled
practitioners can reduce the rate of
abortion-related morbidity and mor-
1965
30 100
Percentage
90
80
70
60
50
40
30
20
10
0
25
Births per 1000 Population
20
15
10
5
0
1967 1969 1971 1973
Abortion restricted
Abortion
restrictions
ended
1975 1977 1979
Year
1981 1983 1985 1987 1989
Crude birth rate
Percentage of maternal deaths caused by abortion
Figure 3. Live births and proportion of maternal deaths due to abortion. Reprinted from The Lancet, Vol. 368,
Grimes DA et al, “Unsafe abortion: the preventable pandemic," pp. 1908-1919, Copyright 2006, with permission
from Elsevier.4
Less restrictive abortion laws also
do not guarantee safe abortions for
those in need; better education and
access to health care are also required.
In India, unsafe illegal abortions
persist despite India’s passage of the
Medical Termination of Pregnancy
Act in the early 1970s. The act ap-
peared to remove legal hindrances to
terminating pregnancies in the under-
funded (national) health care system,
but women still turn to unqualified
local providers for abortion. Clearly,
the implications of the law never
reached the population that most
needed to rely on it.7This example is
also seen in Cambodia, where abor-
tion is legally available on request and
women often attempt to abort them-
selves before turning to hospital.8
Lack of Contraception
Access and Use
More than one-third of all pregnan-
cies are unintended, and 1 in 5 ends
in abortion. In developing countries,
two-thirds of unintended pregnancies
Greater contraceptive access and use alone can drastically reduce unsafe
abortion by reducing unintended pregnancies and all abortion.
9b. RIOG0075_06-11.qxd 6/12/09 4:32 PM Page 125

tality. However, sociopolitical and
religious obstacles have and will con-
tinue to play a role in passing abortion
laws. The roles of research, grassroots
organizations, health providers, ac-
tivists, and media are vital in high-
lighting the importance of relaxing
abortion laws. The emotional, physio-
logic, and financial cost on women and
families, as well as the burden on the
economic health system, should no
longer be ignored.
References
1. World Health Organization. Unsafe abortion:
Global and Regional Estimates of the Incidence
of Unsafe Abortion and Associated Mortality in
2003. 5th ed. Geneva: World Health Organiza-
tion; 2007. http://www.who.int/reproductive-
health/publications/unsafeabortion_2003/ua_
estimates03.pdf.
2. Graham WJ, Ahmed S, Stanton C, et al. Measur-
ing maternal mortality: an overview of opportu-
nities and options for developing countries. BMC
Med. 2008;6:12.
3. Sedgh G, Henshaw S, Singh S, et al. Induced
abortion: rates and trends worldwide. Lancet.
2007;370:1338-1345.
4. Grimes DA, Benson J, Singh S, et al. Unsafe
abortion: the preventable pandemic. Lancet.
2006;368:1908-1919.
5. Singh S. Hospital admissions resulting from
unsafe abortion: estimates from 13 developing
countries. Lancet. 2006;368:1887-1892.
6. Jewkes R, Rees H, Dickson K, et al. The impact of
age on the epidemiology of incomplete abortion
in South Africa after legislative change. BJOG.
2005;112:355-359.
7. Malhotra A, Nyblade L, Parasuraman S, et al,
eds. Realizing Reproductive Choice and Rights:
Abortion and Contraception in India. Washing-
ton, DC: International Center for Research on
Women; 2003. http://www.icrw.org/docs/RCA_
India_Report_0303.pdf
8. Long C, Ren N. Abortion in Cambodia. Country
report. Paper presented at: Advancing the Role
of Midlevel Providers in Menstrual Regulation
and Elective Abortion Care conference; Decem-
ber 2-6, 2001; Pilanesberg National Park, South
Africa.
9. Singh S, Darroch JE, Vlassoff M, Nadeau J.
Adding It Up: The Benefits of Investing in Sexual
and Reproductive Health Care. New York: The
Alan Guttmacher Institute and United Nations
Population Fund; 2003. http://www.guttmacher.
org/pubs/addingitup.pdf.
10. Westoff C. Recent Trends in Abortion and Contra-
ception in 12 Countries. Calverton, MD: MEASURE
DHS; 2005. DHS Analytical Studies No. 8. http://
www.measuredhs.com/pubs/pdf/AS8/AS8.pdf.
11. The Alan Guttmacher Institute. Facts on Induced
Abortion Worldwide. New York: The Alan
Guttmacher Institute; 2008. http://www.
guttmacher.org/pubs/fb_IAW.pdf.
Unsafe Abortion continued
126 VOL. 2 NO. 2 2009 REVIEWS IN OBSTETRICS & GYNECOLOGY
Main Points
• The World Health Organization deems unsafe abortion one of the easiest preventable causes of maternal mortality.
• Data suggest that even as the overall abortion rate has declined, the proportion of unsafe abortion is on the rise.
• Methods of unsafe abortion include drinking toxic fluids; inflicting direct injury to the vagina, cervix, or rectum; or inflicting
external injury to the abdomen. Complications also arise from unskilled providers causing uterine perforation and infections.
• Worldwide, 5 million women are hospitalized each year for treatment of abortion-related complications, and abortion-related
deaths leave 220,000 children motherless.
• Data indicate an association between unsafe abortion and restrictive abortion laws.
• Preventing unintended pregnancy, providing better access to health care, and liberalizing abortion laws to allow services to be
openly provided can reduce the rate of abortion-related morbidity and mortality.
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