Elsevier

The Lancet

Volume 368, Issue 9550, 25 November–1 December 2006, Pages 1908-1919
The Lancet

Series
Unsafe abortion: the preventable pandemic

https://doi.org/10.1016/S0140-6736(06)69481-6Get rights and content

Summary

Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19–20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalisation of abortion on request is a necessary but insufficient step toward improving women's health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves women's health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.

Introduction

Unsafe abortion is a persistent, preventable pandemic. WHO defines unsafe abortion as a procedure for terminating an unintended pregnancy either by individuals without the necessary skills or in an environment that does not conform to minimum medical standards, or both.1 Unsafe abortion mainly endangers women in developing countries where abortion is highly restricted by law and countries where, although legally permitted, safe abortion is not easily accessible. In these settings, women faced with an unintended pregnancy often self-induce abortions or obtain clandestine abortions from medical practitioners,2 paramedical workers, or traditional healers.3 By contrast, legal abortion in industrialised nations has emerged as one of the safest procedures in contemporary medical practice, with minimum morbidity and a negligible risk of death.4 As with AIDS, the disparity between the health of women in developed and developing countries is stark. Unsafe abortion remains one of the most neglected sexual and reproductive health problems in the world today. This article will describe the scope of the problem of unsafe abortion, estimate its mortality and morbidity, document the relation between laws and women's health, estimate costs, and describe prevention strategies. The key messages are presented in panel 1.

Section snippets

Worldwide burden

Worldwide estimates for 1995 indicated that about 26 million legal and 20 million illegal abortions took place every year.5 Almost all unsafe abortions (97%) are in developing countries, and over half (55%) are in Asia (mostly in south-central Asia; table).6 Reliable data for the prevalence of unsafe abortion are generally scarce, especially in countries where access to abortion is legally restricted. Whether legal or illegal, induced abortion is usually stigmatised and frequently censured by

Deaths from unsafe abortion

Measurement of the worldwide prevalence of abortion-related mortality and morbidity is difficult. At a population 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 specific programmatic interventions to changes

Morbidity from unsafe abortion

Morbidity is a much more common consequence of unsafe abortion than mortality, but is determined by the same risk factors. Complications include haemorrhage, sepsis, peritonitis, and trauma to the cervix, vagina, uterus, and abdominal organs (figure 4). High proportions of women (20–50%) who have unsafe abortions are 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

Traditional methods

Nearly 5000 years ago, the Chinese Emperor Shen Nung described the use of mercury for inducing abortion.28 Although one publication18 lists over 100 traditional methods used for inducing abortion, unsafe methods today can be divided into several broad classes: oral and injectable medicines, vaginal preparations, intrauterine foreign bodies, and trauma to the abdomen (panel 2). In addition to detergents, solvents, and bleach, women in developing countries still rely on teas and decoctions made

Legal status of abortion

Increasing legal access to abortion is associated with improvement in sexual and reproductive health. Conversely, unsafe abortion and related mortality are both highest in countries with narrow grounds for legal abortion.33 More than 61% of the world's population resides in countries where induced abortion is allowed without restriction or for a wide range of reasons such as protection of the woman's life, preservation of her physical or mental health, and socioeconomic grounds.34 In 72

Effect of law on health

The prevalence of unsafe abortions remains the highest in the 82 countries with the most restrictive legislations, up to 23 unsafe abortions per 1000 women aged 15–49 years. By contrast, the 52 countries that allow abortion on request have a median unsafe abortion rate as low as two per 1000 women of reproductive age.33 Although the case-fatality rate from unsafe abortions indicates the general level of health care and the availability of post-abortion services, the rate remains the highest in

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

Levels of prevention

Preventive medicine is traditionally viewed in three levels.62 Primary prevention (the domain of public health) protects health by personal and community efforts, such as lowering serum cholesterol and discouraging smoking. Secondary prevention (the domain of preventive medicine) includes early detection and prompt treatment of disease, for example, acute cardiac care for myocardial infarction. Tertiary prevention (rehabilitation) mitigates disability, an example being coronary artery bypass

The public health imperative

The public health rationale to address unsafe abortion was first drawn to attention by the World Health Assembly four decades ago.94 In 1994, the Programme of Action of the International Conference on Population and Development stated, “In circumstances where abortion is not against the law, such abortion should be safe.” The Report of the Fourth World Conference on Women, held in Beijing in 1995, noted “unsafe abortions threaten the lives of a large number of women, representing a grave public

Discussion

Unsafe abortion endangers health in the developing world, and merits the same dispassionate, scientific approach to solutions as do other threats to public health. Although the remedies are available and inexpensive, governments in developing nations often do not have the political will to do what is right and necessary. The beneficiaries of access to safe, legal abortion on request include not only women but also their children, families, and society—for present and future generations.

Women

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