The Global Magnitude and Consequences of Unsafe Abortion Susheela Singh, Ph.D Vice President for Research Regional meeting on Postabortion Care May 2010, Alexandria, Egypt
Summary The magnitude of unsafe abortion Link between safety and legality How unsafe abortions occur Consequences of unsafe abortion Policy and program needs
Definition of unsafe abortion WHO defines unsafe abortion as: A procedure for terminating an unintended pregnancy carried out either (a) by persons lacking the necessary skills or (b) in an environment that does not conform to minimal medical standards, or (c) both conditions apply
Half of the world s unsafe abortions occur in Asia and more than a quarter occur in Africa Africa 2.5% 20% 28% Asia 49% Europe 19.7 million unsafe abortions, 2003 Latin America & Caribbean Note: Less than 1% of unsafe abortions occur in Oceania
Almost all unsafe abortions occur in the developing world World 42 Less developed countries 35 Safe Unsafe More developed countries 7 0 20 40 60 Millions of abortions, 2003
About half of women in the developing world live under highly restrictive abortion laws Developing countries Developed countries Grounds on which abortion is permitted 3% 4% None 31% 7% 25% 16% Only to save woman's life Also to protect woman's physical health 22% 11% 76%, Also to protect woman's mental health Also on socioeconomic grounds 4% 1.3 billion women, 15-44 253 million women, 15-44 Without restriction as to reason
Overall abortion rates declined worldwide between 1995 and 2003, but not the unsafe abortion rate Abortions per 1,000 women aged 15-44 60 50 40 30 20 35 15 39 34 29 29 26 14 18 16 Unsafe Safe 10 0 1995 2003 1995 2003 1995 2003 World More Developed Countries Less Developed Countries
Safe abortion is rare in Africa Abortions per 1,000 women aged 15-44 in 2003 60 50 40 30 20 24 29 39 26 22 24 28 Unsafe Safe 10 0 West Asia Africa East Africa Middle Africa North Africa Southern Africa West Africa
In countries with restrictive abortion laws, providers of abortion are often untrained Percentage of women having abortions 100% Type of provider 80% 60% 40% 20% Woman herself Traditional provider Misoprostol any type of provider (Mexico only) Pharmacist Doctor, nurse or trained midwife 0% Mexico, 2007 Pakistan, 2002 Uganda, 2003 Ethiopia, 2008
Poor women are more likely than non-poor women to experience serious abortion complications Of women having abortions, percentage experiencing serious complications 100 80 66 60 40 42 28 46 31 55 38 41 Poor Nonpoor 20 0 Mexico, 2007 Pakistan, 2002 Uganda, 2003 Ethiopia, 2008
Consequences of Unsafe Abortion Death, ill health, economic and social costs Substantial body of research on mortality and morbidity, but still large gaps Progress during past five years in research on economic and social costs Pilot study in Ethiopia, Mexico and Pakistan National study beginning in Uganda
Unsafe abortion accounts for one in eight maternal deaths Maternal deaths per 100,000 live births, 2003 900 Unsafe abortion 750 All other pregnancyrelated causes 600 450 300 150 0 World Less developed More developed Africa Asia LAC
Abortion-related mortality is highest in regions with restrictive laws and weak health systems Maternal deaths from unsafe abortion per 100,000 live births, 2003 200 150 100 50 115 0 52 59 40 16 World Less developed More developed Africa Asia LAC
Unsafe abortion represents a major public health crisis Almost 70,000 preventable deaths per year, more than half in Africa 5 million women hospitalized per year globally 3 million women do not get the postabortion care they need each year Delay in obtaining care is common and leads to worse health outcomes
Health consequences are often severe and can be long-term Kenya: 28% of post-abortion patients experienced severe complications Nigeria: among hospitalized patients: 1 in 3 had hemorrhage, 1 in 4 sepsis, 1 in 10 had injury. 1/3 of hospitalized cases in Ethiopia and Kenya and 1/5 in Nigeria were in the second trimester Long-term consequences include infertility and chronic infections
Economic cost of unsafe abortion to countries and households are large Postabortion care cost about US $100 per patient in Africa (2006) Direct cost to health systems in Africa was an estimated $170 million in 2006 Impact on households lost productivity, outof-pocket expenses and debt are beginning to be researched Postabortion care is many times the cost of a safe abortion
Contraception is part of the solution: Preventing unintended pregnancy is cost effective Nigeria Estimated $19 million spent annually in treating unsafe abortion complications in Nigeria It would cost only $4.8 million to provide the contraceptive services needed to prevent the pregnancies resulting in these abortions This is a cost-benefit ratio of about 4:1
The social costs of unsafe abortion are widespread and damaging About 200,000 children lose their mothers each year due to abortion-related deaths, globally Women s abortion-related ill-health affects their children and families Internalized stigma - guilt and shame negatively affects women s well-being Perceived or actual stigma e.g. suspicion of infidelity weakens marital relationship Negative attitudes of providers harms women
Women often delay getting care In the words of a Ugandan woman, age 44: [Women]. have the problem of fearing to tell the providers what happened. They fear that they and the people who advised them. can be arrested.. Women fear that if they go to hospital.. they can be arrested and asked to reveal the people who helped them stop the pregnancies.
Most unintended pregnancies occur among women who were not using any contraceptive Modern method 20% Traditional method 14% 66% No method Unintended pregnancies in developing countries, by women s contraceptive use
Unmet need for contraception among married women is declining, but it is still high Latin America & Caribbean Asia 1990-1995 2002-2007 1990-1995 2002-2007 Unmet need Met need No need Africa 1990-1995 2002-2007 0% 20% 40% 60% 80% 100%
Legalization saved lives: South Africa Between 1994-2000, severity of abortion related complications dropped: Fewer post-abortion infections Larger gains by young women Deaths due to unsafe abortion declined by at least 50% Source: Jewkes et al., 2004
Improvements in postabortion care would reduce health consequences Coverage should be expanded to reach women who need and do not get care Misoprostol can help to close this gap Improve quality of postabortion care Increase use of MVA and medication abortion Improve provision of contraception within PAC Reduce negative attitudes of providers
Key interventions to reduce unsafe abortion and its consequences Expand access to modern contraceptives and improve family planning services Expand access to legal abortion and ensure that safe services are available to women in need Improve the quality and coverage of postabortion care, which would reduce maternal death and disability due to unsafe abortion
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