Journal paper

Sexual and Reproductive Health 4

Unsafe abortion: the preventable

pandemic*
David A Grimes, Janie Benson, Susheela Singh, Mariana Romero, Bela Ganatra, Friday E Okonofua,
Iqbal H Shah

Journal paper

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 1920 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 womens 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 womens 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 womens health, estimate
costs, and describe prevention strategies. The
key messages are presented in panel 1.

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

* This is a pre-print copy of a paper published in the journal The Lancet : David A Grimes, Janie Benson, Susheela Singh,
Mariana Romero, Bela Ganatra, Friday E Okonofua, Iqbal H Shah. Unsafe abortion: the preventable pandemic. The Lancet
Sexual and Reproductive Health Series, October 2006.

abortion is usually stigmatised and frequently censured by political,

religious, or other leaders. Hence, under-reporting is routine even in
countries where abortion is legally available.7,8 The use of varying terms,
such as induced miscarriage (fausse couche provoqu),9 menstrual
regulation, mini-abortion, and regulation of a delayed or suspended
menstruation10 further compounds the problem of producing reliable
and comparable estimates of the prevalence of unsafe abortion.
Community studies around the world indicate a higher magnitude of
unsafe abortion than do health statistics.3,11,12 In Zambia, the extent of
maternal mortality from unsafe abortion is not generally known from
health statistics; one study in which women were interviewed revealed
that 69% of the respondents knew one or more women who had
died from an unsafe illegal abortion.12 Focus-group discussions and
community-based studies in India11 revealed self-reported abortions
in 28% of women, which is higher than figures derived from national
service-delivery data.
Estimates show that women in South America, eastern Africa, and
western Africa are more likely to have an unsafe abortion than are
women in other regions. Unsafe abortion rates per 1000 women aged
1544 years (figure 1) provide a more comparable measure of unsafe
abortion by region. In Asia, south-central and southeastern regions have
similar unsafe abortion rates (22 and 21 per 1000 women, respectively),
whereas the rate is about half (12 per 1000) in western Asia and
negligible in eastern Asia (where abortion is legal on request and easily
available).

Panel 1: Key messages

1. An estimated 1920 million unsafe abortions take place every year,
97% of these are in developing countries.
2. Despite its frequency, unsafe abortion remains one of the most
neglected global public health challenges.
3. An estimated 68 000 women die every year from unsafe abortion,
and millions more are injured, many permanently.
4. Leading causes of death are haemorrhage, infection, and poisoning
from substances used to induce abortion.
5. Access to modern contraception can reduce but never eliminate the
need for abortion.
6. Legalisation of abortion is a necessary but insufcient step toward
eliminating unsafe abortion.
7.

When abortion is made legal, safe, and easily accessible, womens

health rapidly improves. By contrast, womens health deteriorates
when access to safe abortion is made more difcult or illegal.

8. Legal abortion in developed countries is one of the safest procedures

in contemporary practice, with case-fatality rates less than one
death per 100 000 procedures.
9. Manual vacuum aspiration (a handheld syringe as a suction
source) and medical methods of inducing abortion have reduced
complications.
10. Treating complications of unsafe abortion overwhelms impoverished
health-care services and diverts limited resources from other critical
health-care programmes.
11. The underlying causes of this global pandemic are apathy and
disdain for women; they suffer and die because they are not valued.

World

Number of unsafe
abortions
(thousands)

Unsafe abortions
per 100
livebirths

Unsafe abortions
per 1000 women
aged 1544
years
14

19 000

14

Developed countries*

500

Developing countries

18 400

15

16

Africa

4 200

14

24

Asia*

10 500

14

13

500

Latin America and the Caribbean

3 700

32

29

Northern America

N/A

N/A

N/A

30

12

17

Europe

Oceania*

Source: WHO.6 *Japan, Australia, and New Zealand have been excluded from the regional
estimates, but are included in the total for developed countries.
N/A=none or negligible incidence.
Table: Global and regional estimates of annual incidence of unsafe abortion, 2000

Temporal trends in unsafe abortion have been inconsistent internationally

(figure 2). Between 1995 and 2000, a decline of 5 or more percentage
points took place in the unsafe abortion rate in eastern, middle, and
western Africa, the Caribbean, and Central America. Other developing
areas had no appreciable change in the rate of unsafe abortion.6
Unsafe abortions vary substantially by age across regions: adolescents
(1519 years) account for 25% of all unsafe abortions in Africa, whereas
the percentage in Asia, Latin America, and the Caribbean is much lower
(figure 3). By contrast, 42% and 33% of all unsafe abortions in Asia and
Latin America, respectively, are in women aged 3044 years, compared
with 23% in Africa.13 For the developing regions as a whole, unsafe
abortions peak in women aged 2029 years. On the basis of WHO
estimates, if current rates prevail throughout womens reproductive
lifetimes, women in the developing world will have an average of about
one unsafe abortion by age 45 years.13
Reasons for seeking abortion are varied: socioeconomic concerns
(including poverty, no support from the partner, and disruption of
education or employment); family-building preferences (including the
need to postpone childbearing or achieve a healthy spacing between
births); relationship problems with the husband or partner; risks to
maternal or fetal health; and pregnancy resulting from rape or incest.14
More proximate causes include poor access to contraceptives and
contraceptive failure.14

Oceania
South America
Central America
Caribbean
Western Asia
Southeastern Asia
South central Asia
Western Africa
Southern Africa
Northern Africa
Middle Africa
Eastern Africa
0

5
10
15
20
25
30
Number of unsafe abortions per 1000 women aged 1544 years

35

40

Figure 1: Estimated number of unsafe abortions per 1000 women aged 1544
years, by subregion
Source: WHO.6 Australia and New Zealand are excluded from estimates of Oceania .

Unsafe abortions per 1000 women aged 1549 years

45

mortality worldwide estimated that abortion accounted for 149% of

such deaths.16 Irrespective of the research methodologies used, the
public health message is clear: unsafe abortion kills large numbers of
women.

1990
1995
2000

40
35
30
25
20
15
10
5

0
Developing
countries

Africa

Asia

Latin America
and Caribbean

Figure 2: Estimated number of unsafe abortions per 1000 women aged

1549 years, by region, 19902000
Source: Special tabulations using WHO database on unsafe abortion .6

About half of all deaths from unsafe abortion are in Asia, with most
of the remainder (44%) in Africa.6 The unsafe abortion mortality ratio
(the number of unsafe abortion-related deaths per 100 000 livebirths)
varies across regions. For the developing world as a whole, this ratio
was estimated to be 60 in the year 2000. However, the ratio is much
higher in eastern, middle, and western Africa (90140), and is lower
in northern and southern Africa, western and southeastern Asia, and
Latin America and the Caribbean (1040). Unsafe abortion is estimated
to account for 13% of all maternal deaths worldwide, but accounts
for a higher proportion of maternal deaths in Latin America (17%) and
southeastern Asia (19%).

Morbidity from unsafe abortion

35+ years

2534 years

2024 years

1519 years

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 (2050%) 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 regulation is legally permitted) to a high of 15 in Egypt
and Uganda.18,19

100

Percentage (%)

80
60
40
20
0
Developing
countries

Africa

Asia

Latin America
and Caribbean

Figure 3: Percentage distribution of unsafe abortions by age

group in the developing world and regions
Source: WHO6

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 in maternal mortality at a population level is rarely feasible
because of the difficulty in accurate measurement of deaths. Moreover,
women might not report their condition or might not relate it to a
complication of an earlier unsafe abortion.15
Worldwide, an estimated 68 000 women die as a result of complications
from unsafe induced abortions every yearabout eight per hour.6 This
prevalence translates into an estimated case-fatality rate of 367 deaths
per 100 000 unsafe abortions, which is hundreds of times higher than
that for safe, legal abortion in developed nations. This ratio is higher
in Africa (709), lower in Latin America and Caribbean (100), and close
to the worldwide average in Asia (324). These differences presumably
indicate regional differences in the safety of abortion provision, the
severity of complications, and access to care thereafter.6 By use of
different methods, a recent systematic review of causes of maternal

Figure 4: Figure 4: Loops of gangrenous small intestine protruding from the

vagina after attempted abortion, 20-year-old woman
Source: Oye-Adeniran.106 Reproduced with permission from Reprod Health Matters 2002;10: 1821.

Morbidity and hospitalisation rates have probably fallen since the early
1990s in response to safer abortion services. In Peru (198998) and in
the Philippines (19942000), the abortion-related hospitalisation rate
droppedby 10% in the Philippines in 6 years and by 33% in Peru
in 9 yearsthough the number of women hospitalised declined much
more slowly.20 Increased use of misoprostol (replacing more invasive
unsafe methods) probably partly accounts for reduced complications.21
In Brazil, the number of women treated in public hospitals for abortion
complications dropped by about 28% over 13 years (from 345 000 in
1992 to 250 000 in 2005).22 However, most of this decline took place
between 1992 and 1995, and the number has varied little since then.
Whereas increased use of misoprostol might have accounted for
some of the early decline in abortion-related morbidity, the stability
3

of the number suggests that most women who have an abortion with
misoprostol still seek treatment at public hospitals (Anibal Faundes,
personal communication, July 5, 2006).
Severity of complications is another important measure of effects on
health. A standardised measure of the severity of complications was
used in South Africa before and after legalisation of abortion on request
in 1996.23 The proportion of women classified with severe complications
(fever of 38C or more, organ or system failure, generalised peritonitis,
pulse 120 per min or more, shock, evidence of a foreign body, or
mechanical injury) in South Africa fell substantially from 165% before
legalisation to 97% after. Applying similar methods, a study in Kenya
found that 28% of hospitalised women had severe complications.
Gestational age at abortion is a simple predictor of risk: later abortions
are associated with increased risks for the woman. Late abortions
are common; for example, a third of women treated for abortion
complications in public hospitals in Kenya were beyond the first
trimester.24 By contrast, spontaneous abortions are uncommon after the
first trimester, suggesting that many of these complications stemmed
from induced unsafe abortions.
Information on long-term health consequences of unsafe abortion is
scarce. The WHO estimates that about 2030% of unsafe abortions
result in reproductive tract infections and that about 2040% of these
result in upper-genital-tract infection and infertility. An estimated 2% of
women of reproductive age are infertile as a result of unsafe abortion,
and 5% have chronic infections.6 Unsafe abortion could also increase
the long-term risk of ectopic pregnancy, premature delivery, and
spontaneous abortion in subsequent pregnancies. Little is known about
women who have complications but who do not seek medical care.
Clinicians estimate that the proportion of such women was 14% in Latin
America, 19% in south and southeast Asia, and 26% in Nigeria.18 Similar
studies in Guatemala and Uganda yielded estimates of about 20%.19,25
Delays in recognising the need for care and in arranging transportation
are common. On reaching a health-care facility, women with
complications of unsafe abortion are often met with suspicion or hostility.
Their treatment is deferredsometimes indefinitely.26 This disdain
compounds the poor staff training, inoperative equipment, out-of-stock
drugs, sporadic supplies of water and electricity, and transportation
challenges hampering developing-country health-care facilities.
Life-threatening sepsis or haemorrhage might mean a hysterectomy.
Gas gangrene from Clostridium perfringens is common with insertion
of foreign bodies, and tetanus threatens women who have not been
immunised. Women with retained tissue and severe infections might
receive only oral tetracycline until they are deemed stable enough for
curettage in an operating theatre; many die needlessly during the wait.
Delays are especially dangerous when bowel injuries cause peritoneal
contamination.27

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
from local plant or animal products, including dung. Foreign bodies
inserted into the uterus to disrupt the pregnancy often damage the
4

uterus and internal organs, including bowel. In settings as diverse as

the South Pacific and equatorial Africa, abortion by abdominal massage
is still used by traditional practitioners. The vigorous pummelling of
the womans lower abdomen is designed to disrupt the pregnancy but
sometimes bursts the uterus and kills the woman instead.29
The primitive methods used for unsafe abortion show the desperation
of the women. Surveys done in New York City before the legalisation of
abortion on request documented the techniques in common use.30 Of
899 women interviewed, 74 reported having attempted to abort one
or more pregnancies; 338 noted that one of their friends, relatives, or
acquaintances had done so. Of those reported abortion attempts, 80%
tried to do the abortion themselves. Nearly 40% of women used a
combination of approaches. In general, the more invasive the technique,
the more dangerous it was to the woman and the more likely it was
to disrupt the pregnancy. Invasive methods, such as insertion of tubes
or liquids into the uterus, were more successful than were other
approaches. Coat hangers, knitting needles, and slippery elm bark were
common methods; the bark would expand when moistened, causing
the cervix to open. Another widely used method was to place a flexible
rubber catheter into the uterus to stimulate labour.
Surveys suggest that miscellaneous methods and oral medications,
such as laundry bleach, turpentine, and massive doses of quinine, were
most commonly used in New York.30 Injection of toxic solutions into the
uterus with douche bags or turkey basters was common. Absorption of
soap solutions into the womans circulation could cause renal toxicity
and death.31 Potassium permanganate tablets placed in the vagina
were also common; these did not induce abortion but could cause
severe chemical burns to the vagina, sometimes eroding through to the
bowel.32

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 worlds population resides in countries
where induced abortion is allowed without restriction or for a wide
range of reasons such as protection of the womans life, preservation
of her physical or mental health, and socioeconomic grounds.34 In 72
countries, most of which are in the developing world, 26% of the worlds
population lives where abortion is prohibited altogether or allowed only
to save the womans life.34 Most of these restrictive laws originated from
European colonial laws from previous centuries, although the European
nations discarded their restrictive abortion laws decades ago.
Between 1995 and 2005, 12 countries increased access to legal
abortion, including Albania, Benin, Burkina Faso, Cambodia, Chad,
Ethiopia, Guinea, Guyana, Mali, Nepal, South Africa, and Switzerland.35,36
The strategies used to achieve reform vary by country. Nepals reforms in
2002, for example, were part of an overall womens rights bill and permit
legal abortion with no restriction in the first 12 weeks of pregnancy and
afterwards on specific grounds. The previous law allowed no indications
for abortion.35 The post-apartheid movement for expanded equality
in South Africa led to the 1996 act that allows legal abortion without
restriction during the first 12 weeks of pregnancy and afterwards on
numerous grounds. Only narrow indications for legal abortion had been
previously allowed.35 In early 2006, Colombias constitutional court
ruled in favour of expanded indications for legal abortion, including
when a womans life or health is in danger and in cases of rape or fetal
malformation.37

Panel 2: Part inventory of unsafe abortion methods, by route of administration93

Treatments taken by mouth

Intramuscular injections

Toxic solutions

Two cholera immunisations

Turpentine

Foreign bodies placed into the uterus through the cervix

Laundry bleach

Stick, sometimes dipped in oil

Detergent solutions

Lump of sugar

Acid

Hard green bean

Laundry bluing

Root or leaf of plant

Cottonseed oil

Wire

Arak (a strong liquor)

Knitting needle

Teas and herbal remedies

Rubber catheter

Strong tea

Bougie (large rubber catheter)

Tea made of livestock manure

Intrauterine contraceptive device

Boiled and ground avocado or basil leaves

Coat hanger

Wine boiled with raisins and cinnamon

Ballpoint pen

Black beer boiled with soap, oregano, and parsley

Chicken bone

Boiled apio (celery plant) water with aspirin

Bicycle spoke

Tea with apio, avocado bark, ginger, etc

Air blown in by a syringe or turkey baster

Bitter concoction

Sharp curette

Assorted herbal medications

Enemas

Drugs

Soap

Uterine stimulants, such as misoprostol or oxytocin

(used in obstetrics)

Shih tea (wormwood)

Quinine and chloroquine (used for treating malaria)

Abdominal or back massage

Oral contraceptive pills (ineffective in causing abortion)

Lifting heavy weights

Treatments placed in the vagina or cervix

Jumping from top of stairs or roof

Trauma

Potassium permanganate tablets

Herbal preparations
Misoprostol

Advocacy for increased access to safe legal abortion has increased in

countries such as Argentina, Brazil, Indonesia, Jamaica, Kenya, Mexico,
Mozambique, Nigeria, Trinidad and Tobago, Uganda, and Uruguay. These
efforts are rooted in public health, human rights, and other arguments.
Those involved include health and medical professionals, womens
groups, legal and human rights advocates, young people, government
officials, and, in some countries, trade unionists.38
Several countries have restricted abortion laws in the past decade.
El Salvador amended its penal code in 1998 to ban abortion for any
legal indication; previous indications had included saving a womans
life, pregnancy resulting from rape, and fetal impairment (panel 3).35
In 1997, Polands Parliament approved legislation removing social
and economic grounds for abortion.35 Anti-abortion voices continue
to protest against attempts at legal reform in countries as diverse as
Nicaragua, Sri Lanka, and Uruguay. The recent legislation for safer
access in Colombia prompted a Roman Catholic cardinal to suggest civil
disobedience and to threaten excommunication of judges who voted to
support safer laws.39

Panel 3: Prosecution in El Salvador

After I came out of the coma, they moved me to the maternity hospital. My
brother visited and asked me if the police had come to ask me questions.
He said the police had come to our house and they had interrogated our
relatives and neighbours. They had gone to where I worked. They asked
everyone a lot of questions about me and who I was and if they knew
whether I was pregnant and whether Id had an abortion.
When I got home, the prosecutor came to see me, and he asked lots of
aggressive questions. He talked to me like I was a criminal. I didnt want to
answer because I was scared. He said if I didnt answer, even though I was
in bad physical shape, he would put me in jail. He wanted me to tell him who
the father of the child was and the name of the person who had done this
to me. I didnt know her name. Then he made a date for me to come to the
prosecutors ofce.
Anonymous woman in El Salvador40

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 1549 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 countries where abortion is legally restricted. In such countries, the
median ratio for unsafe abortion mortality is 34 deaths per 100 000
livebirths; this ratio steadily decreases as legal grounds for abortion
increase. The ratio falls to one or less per 100 000 livebirths in countries
that allow abortion on request.33 Even in countries where improved
access to health care and emergency obstetric services has greatly
reduced overall maternal mortality, restrictive abortion laws translate
into abortion deaths constituting a disproportionately high share of
maternal deaths (panel 4).41
Panel 4: Romania and South Africa
Widespread access to legal abortions on request in Romania from 1957
onwards led to a decline in unsafe abortions with an abortion mortality
ratio of 20 per 100 000 livebirths in 1960.6,42 Mortality began to rise
steadily as Ceausescus pronatalist restrictive policy imposed in 1966
began to take effect (gure 5). By 1989 mortality ratios had risen sevenfold to peak at 148 deaths per 100 000 livebirths; abortion accounted for
87% of the deaths. When Ceausescu was deposed in 1989, the immediate
change of laws reversed this trend. The mortality ratio fell by more than
half to 68 within the rst year of safer access itself. By 2002, mortality
from unsafe abortions was as low as nine per 100 000 livebirths; abortion
deaths accounted for less than half of maternal deaths.43
Abortion became legal and available on request in South Africa in 1997.44
The Choice on Termination of Pregnancy act No 92 was promulgated in
South Africa on Oct 31, 1996, but went into effect on Feb 1, 1997. Since
then, the resulting favourable environment has increased womens
access to family planning, abortion, and post-abortion care services in the
country. After the law was passed, abortion-related deaths dropped 91%
from 1994 to 19982001.23
The new law increased womens access to a broad range of options for
the prevention and treatment of unwanted pregnancy. In particular, the
law led to the increased promotion of family planning, the increased use
of manual vacuum aspiration for abortion and post-abortion care, use of
manual vacuum aspiration by nurses and midwives, and the introduction
of medical abortion methods.

Making abortion legal, safe, and accessible does not appreciably increase
demand. Instead, the principal effect is shifting previously clandestine,
unsafe procedures to legal and safe ones. Hence, governments need
not worry that the costs of making abortion safe will overburden the
health-care infrastructure.18 Countries that liberalised their abortion
laws such as Barbados, Canada, South Africa, Tunisia, and Turkey did
not have an increase in abortion. By comparison, the Netherlands, which
has unrestricted access to free abortion and contraception, has one of
the lowest abortion rates in the world.18
In several countries, legal inquiry, prosecution, and even imprisonment
of women who have had an unlawful abortion is not uncommon.40
Before the 2002 law change in Nepal, an estimated 20% of the women
prisoners nationwide were in jail for charges relating to abortion or
6

infanticide. Many women who had miscarriage, stillbirths, or induced

abortions were jailed on charges of infanticide.45
Enabling abortion legislation is necessary but not sufficient: a new
law might not translate into widespread access to safe services. India
and Zambia both legalised abortion in the early 1970s, but safe, legal
abortion remains largely unavailable.46 In India, access through the
public health system is mainly restricted to cities. Despite a mandate
to provide abortion services, in most states fewer than 20% of primary
health care centres do so. Many centres only sporadically provide
service either because of a shortage of trained physicians or functioning
equipment.47
Access to safe abortion is also mediated by womens awareness of the
law. Knowledge is often poor, even in countries with longstanding liberal
laws. Misperceptions about the specifics of the law are not uncommon,
thus making women vulnerable to poor care, financial exploitation,
and prosecution.45,48,49 Even where legal abortion is widely available
on request, misperceptions about the legality of minors having sexual
intercourse delay some adolescents from seeking care. In many cultures,
perceptions of legality are affected by the stigma attached to premarital
or extramarital sexual activity. In several south Asian countries, such
pregnancies are commonly referred to as illegal or illegitimate, as are
the abortions induced in these circumstances.50 Misperceptions about
legal requirements, such as the need for spousal authorisation and
provider attitudes, could create barriers that do not exist in law. These, in
turn, might drive unmarried women to unsafe providers (compromising
medical safety for confidentiality 47,51) or to suicide.52

Costs of unsafe abortion

Treatment of abortion complications burdens public health systems in
the developing world. Conversely, ensuring womens access to safe
abortion services lowers medical costs for health systems. In some lowincome and middle-income countries, up to 50% of hospital budgets
for obstetrics and gynaecology are spent treating complications of
unsafe abortion.18 A review of medical records in 569 public hospitals in
Egypt during 1 month noted that almost 20% of the 22 656 admissions
to obstetrics and gynaecology departments were for treatment of an
induced or reportedly spontaneous abortion.53
Direct costs include health personnel, medications, blood, supplies and
equipment, and overnight stays. The cost per woman to health systems
for treatment of abortion complications in Tanzania is more than seven
times the overall Ministry of Health budget per head of population.54
Estimates from Uganda comparing costs of treatment of abortion
complications with costs of providing safe, elective abortion show the
potential resource-savings to health systems. Post-abortion care offered
in tertiary hospitals by physician providers was estimated to cost health
systems ten times more than elective abortion services offered by midlevel practitioners in primary care (Heidi Johnston, 2004; Ipas, Chapel
Hill, NC, USA).
In sub-Saharan Africa, two studies attempted to estimate costs at the
national level. A 1997 South African study estimated that the total yearly
cost of treating unsafe abortion morbidity in public hospitals was ZAR
974 million (about US$14 million).55 A 2002 study in Nigeria estimated
that the total national cost of direct medical care for treating abortion
complication patients was NGN 1400 million ($117 million).56 A second
study in Nigeria estimated that the national cost of treating unsafe
abortion complications in 2005 was $19 million (Akinrinola Bankole,
unpublished data).

30

Crude birth rate

Levels of prevention

100

Percentage of maternal deaths caused by abortion

90
80
70

20

60
15

50

40
10

Percentage

Births per 1000 population

25

30
20

5
Abortion restricted

10

Abortion restrictions ended

0
1965

1967

1969

1971

1973

1975

1977

1979

1981

1983

1985

1987

1989

Year

Figure 5: Livebirths and proportion of maternal deaths due to abortion,

Romania, 196590
Source: David.42 Data unavailable for 1979.

Use of manual vacuum aspiration for management of first-trimester

incomplete abortions reduces costs. Studies in Bolivia, Mexico, and
Peru showed that although the cost per patient for inpatient dilatation
and curettage services ranged from $66151, a change to ambulatory
manual vacuum aspiration reduced costs to $3366, a decrease of
5672%.57 Per-patient costs in Kenya fell by 23% in one hospital and
66% in another when post-abortion care services were changed from
dilatation and curettage to manual vacuum aspiration in outpatients.58
Reductions in overall costs per patient were attributable to shortened
hospital stays, less staff time, and fewer medications.

Indirect costs
The indirect costs of unsafe abortion are substantial, yet more difficult
to quantify. They include the loss of productivity from abortion-related
morbidity and mortality on women and household members; the effect
on childrens health and education if their mother dies; the diversion
of scarce medical resources for treatment of abortion complications;
and secondary infertility, stigma, and other sociopsychological
consequences. For example, an estimated 220 000 children worldwide
lose their mothers every year from abortion-related deaths.59 Such
children receive less health care and social care than children who have
two parents, and are more likely to die.60
Estimates of disability adjusted life-years (DALYs) provide an indicator
of one part of the indirect costs, womens loss of productive life. An
estimated 5 million DALYs are lost per year by women of reproductive
age as a result of mortality and morbidity from unsafe abortion.61
However, this rate probably underestimates the true burden because of
limitations in the methods of estimating DALYs resulting from maternal
causes.59
Stigma impairs health, both directly through harm to wellbeing and
indirectly by hindering prompt access to medical care. Stigma related to
abortion particularly affects adolescents and unmarried women because
of their inexperience and few economic resources.26 Social sanctions
against sexual activity are especially problematic for unmarried
women.

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 grafting. In general, primary prevention is preferable to
secondary and tertiary prevention in terms of both cost and compassion:
immunising against poliomyelitis is better than building iron lungs.
Primary prevention includes reduction in the need for unsafe abortion
through contraception, legalisation of abortion on request, the use
of safer techniques, and improvement of provider skills. Access to
safe, effective contraception can substantially reducebut never
eliminatethe need for abortion to regulate fertility. The effect of
national contraceptive programmes on reducing the rate of abortion is
well documented. In seven countries (Bulgaria, Kazakhstan, Kyrgyzstan,
Switzerland, Tunisia, Turkey, and Uzbekistan), abortion rates fell as
use of modern contraception rose.63 In another six countries (Cuba,
Denmark, Netherlands, Republic of Korea, Singapore, and USA), abortion
and contraception increased simultaneously; the uptake of effective
contraception did not keep pace with couples increasing desires for
smaller family sizes.
In several of the six countries, abortion rates ultimately declined with
continued contraceptive use and stabilisation of fertility rates at lower
levels. Even with high rates of contraceptive use, however, unintended
pregnancies will continue. No contraceptive method is 100% effective,
and many couples in the developing world still encounter obstacles
to contraception.64 Every year, 80 million women worldwide have an
unintended pregnancy, and 60% of these are aborted.18 Thus, the need
for safe abortion will continue.
The developing world has seen a revolution in contraceptive usefrom
a mere 9% of couples using any method in 19606565 to 59% in
2003.66 Nevertheless, an estimated 27 million unintended pregnancies
happen worldwide every year with the typical use of contraceptives.
Six million would happen even with perfect (i.e., correct and consistent)
use.67 An estimated 123 million women have an unmet need for family
planning.68
All abortion patientswhether seeking treatment of a complication or an
elective induced abortionshould be offered contraceptive counselling
and a choice of appropriate methods. Results of many studies in Latin
America and Africa have shown that after having an abortion patients
will accept contraception at high rates.57,6971 Contraceptive counselling
and provision at the time of treatment reduced unintended pregnancies
and repeat abortions by 50% over 1 year in Zimbabwe, compared with
post-abortion patients who did not receive such services.72
The advent of vacuum aspiration in the 1960s1 revolutionised the primary
prevention of complications in developing countries. This technology
(figure 6) relies on the use of a simple syringe with a plunger to generate
negative pressure for uterine evacuation, and plastic cannulas of varying
sizes. The amount of negative pressure obtained with manual vacuum
aspiration is similar to that generated with large, expensive, electrical
pumps, which makes this method especially suited for use in clinics,
offices, and low-resource settings. Manual vacuum aspiration also has

the advantage that the syringe can be cleaned, high-level disinfected, or

sterilised and used repeatedly; similarly, cannulas can be discarded or
re-used after appropriate disinfection or sterilisation.
Vacuum aspiration is safer than sharp curettage, and the WHO
recommends vacuum aspiration as the preferred method for uterine
evacuation before 12 weeks of pregnancy.67 This method is faster, safer,
more comfortable, and associated with shorter hospital stay for induced
abortion than sharp curettage.73,74 Additional advantages compared with
sharp curettage are its ease of use as an outpatient procedure, the need
for less analgesia and anaesthesia,75 and its lower cost per procedure
especially if done on an outpatient basis.76 In countries with a small
number of physicians, vacuum aspiration can be safely and effectively
used by mid-level health service providers, such as midwives.77

The results of a survey in Addis Ababa showed that almost 30% of

maternal deaths in the city resulted from unsafe abortion.90 To address
the high maternal mortality rate (estimated to be 850 deaths per
100 000 livebirths), the Ministry of Health, Regional Health Bureaus,
and several international non-governmental organisations joined forces
to improve post-abortion care in the public-health sector. Interventions
include clinical training of physicians and midwives, provision of manual
vacuum aspiration and other supplies, reorganisation of services,
supervisory visits to facilities, and improved record-keeping. Postabortion care was implemented in 42 health-care facilities in three
regions assessed from 2000 to 2004. Quality of care also improved.91
In 2004, Ethiopia revised its abortion law and in 2006 issued guidelines
for safe abortion services.
Critics of post-abortion care worldwide complain that the preoccupation
with secondary (rather than primary) prevention of unsafe abortion
is myopic, tantamount to placing ambulances at the bottom of a cliff
instead of erecting a fence at the top.
Tertiary prevention mitigates long-term damage. Rapid transfer to
a hospital can be lifesaving.92 Prompt repair of uterine injury could
preserve fertility. Acute renal failure and tetanus from unsafe abortions
remain important causes of death and lengthy disability.93 Repair of
fistulas in bowel and bladder can end the suffering, stigmatisation, and
abandonment that these injuries cause.

Figure 6: Manual vacuum aspiration syringe

The combined use of mifepristone and misoprostol has become the

standard WHO-recommended medical regimen for early medication
abortion,67 and is better than either drug alone.78 Misoprostol is a
prostaglandin E1 analogue marketed for the prevention and treatment
of gastric ulcers. However, mifepristone can be expensive and is not
available in much of the world, whereas misoprostol is cheap and
widely available. Regimens with misoprostol alone as an abortifacient
have varied widely, with reported success rates ranging between 87%
and 97%.79 Increased access to misoprostol has been associated with
improved womens health in developing countries, and studies are being
done to refine the regimen for misoprostol alone to induce abortion
(panel 5).
Secondary prevention entails prompt and appropriate treatment of
complications. This includes timely evacuation of the uterus after
incomplete abortion. WHO has issued technical and clinical guidelines
for the provision of safe abortion care67 and treatment of abortion
complications.1 Misoprostol can be used for the management of
incomplete abortion,86 and vacuum aspiration is better than sharp
curettage.87,88
Post-abortion care is spreading worldwide. In Guatemala, with support
from the Ministry of Health, the Centro de Investigacin Epidemiolgica
en Salud Sexual y Reproductiva began in 1996 a series of training-oftrainers with teams of nurses and doctors around the country. Content
included post-abortion assessment and diagnosis, uterine evacuation
procedures and techniques, pain management, infection prevention,
management of complications, referral to other sexual and reproductive
health services, contraceptive counselling and provision, and follow-up
care.89

Panel 5: Misoprostol in South America

After introduction into Brazil in 1986, misoprostol became available
over the counter. Soon, women recognised its effectiveness as an
abortifacient and began to use the drug for this purpose. Women would
self-administer the drug orally and then seek medical assistance if
the uterine bleeding did not stop. By 1990, 70% of women treated
in hospital for abortion complications in Brazilian hospitals reported
having used misoprostol.80 The report of a rapid increase in uterine
evacuation procedures done in some hospitals as a result of abortions
initiated by misoprostol81 led the Ministry of Health to restrict its sale
in 1991. The State of Ceara banned the drug altogether. However,
restricting access to the drug did not prevent its use; rather, the drug
remained widely available in the black market at inated prices.
Consequently, the rate of abortion complications increased after
restriction. Indeed, in Campinas, abortion-related deaths tripled after
restricted access to misoprostol.80
Womens use of misoprostol in Brazil decreased the severity of unsafe
abortion complications, and to some extent also decreased the number
of women admitted to hospital. Previously, women would insert foreign
bodies into their cervix, which provoked bleeding and led to completion
by curettage in hospital. Misoprostol is less likely to cause infection
than are foreign bodies.82 One hospital recorded a rate of uterine
infection of 4% in women who reported using misoprostol, compared
with 8% in women who reported having a spontaneous abortion.83
Use of medical abortion has also expanded in Peru.84 Although the
use of prostaglandins for abortion was infrequent in a 1989 survey,
most key informants mentioned it in a similar survey in 1998,85 even
in remote regions of the country. The wide use of prostaglandins for
abortion has been associated with improved health for women. In
three other countries, women have widely accepted medical abortion
because of its similarity to spontaneous abortion.21

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 health problem as it is primarily the poorest and youngest
who take the highest risk.96 At the Special Session of the UN General
Assembly in June, 1999, governments agreed that in circumstances
where abortion is not against the law, health systems should train
and equip health-service providers and should take other measures
to ensure that such abortion is safe and accessible.97 By investing in
abortion safety and availability, governments throughout the world can
save the lives of tens of thousands of women every year.6,18,98
Increasingly, private foundations and donor governments, including the
UK, Netherlands, Sweden, Norway, Denmark, and Finland, have funded
activities to advance access to safe abortion. By contrast, the USA
has since 1974 precluded use of development assistance for abortion
services. In 2001, the US government re-introduced the even more
restrictive Mexico City Policy, known by opponents as the Global Gag
Rule. According to this policy, private organisations outside the USA are
eligible for family planning assistance only if they agree not to engage in
most abortion-related activities, even with their own funds.99
International organisations increasingly regard the denial of safe
abortion services as a human-rights violation. In 1999, the UN
Committee on the Elimination of All Forms of Discrimination Against
Women (CEDAW) determined that neglect of health services that only
women need is discriminatory and a deficit that governments must
remedy. Furthermore, CEDAW noted that criminalisation of abortion is a
barrier that states should remove.100
In 2005, the UN Human Rights Committee ruled against Peru for its
denial of a legal abortion; the woman had an anencephalic fetus and
was forced to continue the pregnancy to delivery.101 The Inter-American
Commission on Human Rights ruled in favour of a 13-year-old Mexican
girls petition; she had been raped and subsequently denied access to a
legally permitted abortion by state health and law enforcement officials
in Mexico.102 As a result, the Mexican government will issue guidance for
access to abortion for rape victims. Moreover, the government agreed to
compensate the young woman and her son for health care, education,
and professional development. The 2005 Protocol to the African Charter
on Human and Peoples Rights on the Rights of Women in Africa is the
first international human rights instrument to provide for abortion as a
right.103

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 societyfor present and future generations.
Women have always had abortions and will always continue to do
so, irrespective of prevailing laws, religious proscriptions, or social
norms.104 Although the ethical debate over abortion will continue, the

public-health record is clear and incontrovertible: access to safe, legal

abortion on request improves health.73 As noted by Mahmoud Fathalla,
Pregnancy-related deaths are often the ultimate tragic outcome of
the cumulative denial of womens human rights. Women are not dying
because of untreatable diseases. They are dying because societies have
yet to make the decision that their lives are worth saving.105 Simply put,
they die because they do not count.
Conflict of interest statement
DG, a gynaecologist, has done, taught, and studied abortions for 33 years. He has
performed abortions as part of his duties as a medical school faculty member
and as a private contractor for freestanding abortion clinics. He has served on
the Board of Directors of the National Abortion Rights Action League and Planned
Parenthood Federation of America.
He is a member of the National Abortion Federation, the American College of
Obstetricians and Gynecologists, the American Public Health Organization and
other groups that support safe, legal abortion. He is a past chair of the Task
Force on Postovulatory Fertility Control of the WHO, which conducts abortion
research. He is an editor of a textbook on abortion and a chapter contributor
to a gynecology text, both of which have provided modest royalties (less than
$1000 total). He has testified in defence of physicians in medical liability cases
concerning abortion. He has testified before Congressional committees twice
regarding abortion. He has received honoraria for speaking about abortion at
medical meetings. He currently teaches and performs abortions at the University
of North Carolina School of Medicine as part of his faculty duties.
He receives a fixed salary from the university, which is not dependent upon
the number of abortions he does. JB is an employee of Ipas, a global, nonprofit reproductive health organisation focused on safe abortion and womens
reproductive rights. Ipas manufactures and distributes manual vacuum
aspiration instruments worldwide. SS is employed by the Guttmacher Institute,
an organisation committed to improving sexual health and rights, including
improving access to safe and legal abortion services. FEO, MR, and BG are
members of the steering committee of the International Consortium for Medical
Abortion, which aims at expanding access to medical abortion in the context
of safe abortion worldwide. BG is a full time salaried employee of Ipas and has
never been a provider of abortion services. She has received financial support
for and been the principal investigator on several social science studies on
maternal health and unsafe abortion. FEO is the Executive Project Director
of the International Federation of Obstetricians and Gynecologists and the
Honorary Adviser to the President of Nigeria on Maternal and Child Health. He
is a member of the Abortion Research Consortium in Africa, and a consultant
to several international organisations on abortion matters in Africa. Through
the NGO which he founded in 1995, the Womens Health and Action Research
Centre, he has received funding specifically from the Lucile and David Packard
Foundation to build capacity for safe abortion service delivery among private
practitioners in northern Nigeria. He has received very modest honoraria for
speaking on abortion in Africa at several international fora. He receives a fixed
salary from the university, which is not dependent on his research on abortion.
IHS is a social scientist with the Special Programme in Human Reproduction,
and coordinator of the Programmes Team on Preventing Unsafe Abortion. His
duties include supporting research on social science and operations research in
sexual and reproductive health, including users perspectives on family planning
and adolescent and reproductive health. He has given lectures with no financial
renumeration from any source besides the fixed salary and associated benefits
from WHO. All authors have no financial stake in any abortion clinic, and own no
individual stocks in any drug company or medical supply house that might profit
from abortion.

Acknowledgments
We thank Elisabeth hman, Patty Skuster, and Barbara Crane. I Shah
is a staff member of the World Health Organization. The author is
responsible for the views expressed in this publication and they do
not necessarily represent the decisions, policies, or views of the World
Health Organization.
9

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For more information, please contact:

Department of Reproductive Health and Research
World Health Organization
Avenue Appia 20, CH-1211 Geneva 27
Switzerland
Fax: +41 22 791 4171
E-mail: [email protected]
www.who.int/reproductive-health

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