Unsafe abortion: global and regional incidence, trends, consequences, and challenges

OBJECTIVE

This review aims to provide the latest global and regional estimates of the incidence and trends in induced abortion, both safe and unsafe. A related objective is to document maternal mortality due to unsafe abortion. The legal context of abortion and the international discourse on preventing unsafe abortion are reviewed to highlight policy implications and challenges in preventing unsafe abortion. METHODS AND DATA SOURCES: This review is based on estimates of unsafe abortion and maternal mortality ratios. These estimates are arrived at using the database on unsafe abortion maintained by the World Health Organization. Additional data from the Demographic and Health Surveys and the United Nations Population Division are used for further analysis of abortion and mortality estimates.

RESULTS

Each year 42 million abortions are estimated to take place, 22 million safely and 20 million unsafely. Unsafe abortion accounts for 70,000 maternal deaths each year and causes a further 5 million women to suffer temporary or permanent disability. Maternal mortality ratios (number of maternal deaths per 100,000 live births) due to complications of unsafe abortion are higher in regions with restricted abortion laws than in regions with no or few restrictions on access to safe and legal abortion.

CONCLUSION

Legal restrictions on safe abortion do not reduce the incidence of abortion. A woman's likelihood to have an abortion is about the same whether she lives in a region where abortion is available on request or where it is highly restricted. While legal and safe abortions have declined recently, unsafe abortions show no decline in numbers and rates despite their being entirely preventable. Providing information and services for modern contraception is the primary prevention strategy to eliminate unplanned pregnancy. Providing safe abortion will prevent unsafe abortion. In all cases, women should have access to post-abortion care, including services for family planning. The Millennium Development Goal to improve maternal health is unlikely to be achieved without addressing unsafe abortion and associated mortality and morbidity.

On how to interpret the role of the future within the abortion debate

In a previous paper, I had argued that Strong's counterexamples to Marquis's argument against abortion-according to which terminating fetuses is wrong because it deprives them of a valuable future-fail either because they have no bearing on Marquis's argument or because they make unacceptable claims about what constitutes a valuable future. In this paper I respond to Strong's criticism of my argument according to which I fail to acknowledge that Marquis uses "future like ours" and "valuable future" interchangeably. I show that my argument does not rely on not acknowledging that "future like ours" and "valuable future" are interchangeable; and that, rather, it is exactly by replacing "future like ours" with "valuable future" that I construct my argument against Strong. I conclude with some remarks on how Marquis's concept of "future like ours" should be interpreted.

[The reform of Spanish abortion law]

The article focuses on the different factors and circumstances that have led to the reform of Spanish Abortion Law (1985). Judicial investigations of several abortion clinics have demonstrated that up until today there has been a widespread tendency of the clinics to practice beyond the limits established by the law. Nonetheless, the reaction of the government has not been to protect the life of the unborn. Its reaction has been, however, to cover the irregularities committed by the abortionists through the legalization of their abusive practices. Besides, the reform of the law has been inspired by elements of radical feminism. The author points out the major reasons that make this reform unconstitutional and offers alternative solutions for the protection of the mother and the unborn child.

[The causes of abortions among adolescents residing in the rural area]

The paramount role in the prevention of artificial pregnancy interruption among adolescents is attached to the healthy life-style of family, the content of family relationship, the confidential relationship between children and their parents (including issues related to sexual life). Besides, it is worth to notice the importance of the source of information related to the intimate issues during period of education and the resolution of everyday life problems such as separate room for adolescent dwelling, factual income per one family member etc. In the artificial interruption of pregnancy the special role is applied to the medical factors related to the degree of consistency of chosen techniques of contraception and the availability of extra-genital pathology. The examined factors permit to establish the directions of targeted and hence more effective approach to the organization of preventive measures related to the unwanted pregnancy.

Trends in family planning in Russia, 1994-2003

CONTEXT

Although Russian women have adequate knowledge of modern contraceptives, their level of use of these methods has been low, and abortion rates remain relatively high.

METHODS

In 1994-2003, sexually active women aged 18-49 were interviewed about their contraceptive use as part of the Russia Longitudinal Monitoring Survey. Trends in contraceptive use were examined. Multivariate analyses were conducted to identify characteristics associated with reliable contraceptive use (IUD use or consistent oral contraceptive use) in 1994 and 2003.

RESULTS

In each year, about 25% of sexually active women had used no contraceptive method in the past month, and 20% had used traditional methods. Prevalence of barrier method use increased from 9% to 21% between 1994 and 2003, while that of IUD use declined from 34% to 21%. These changes were especially pronounced in Moscow and St. Petersburg, and among younger women. Common reasons for nonuse were irregular sexual relations (cited by 29% of nonusers in 2003), desire for pregnancy (22%), perceived inability to get pregnant (15%), feeling that contraceptives are uncomfortable or unpleasant (15%), health problems (11%) and the availability of abortion (6%). In 1994 and 2003, the odds of reliable contraceptive use were elevated among women with at least a secondary education (odds ratios, 1.5-1.7), and were reduced among smokers (0.6-0.7).

CONCLUSIONS

Modern, effective contraceptive use has not increased among sexually active Russian women. Growing use of barrier contraceptives may reflect HIV awareness. Obstacles to effective contraceptive use, such as attitudes and health service factors, need further clarification.

Trends in family planning in Russia, 1994-2003

CONTEXT

Although Russian women have adequate knowledge of modern contraceptives, their level of use of these methods has been low, and abortion rates remain relatively high.

METHODS

In 1994-2003, sexually active women aged 18-49 were interviewed about their contraceptive use as part of the Russia Longitudinal Monitoring Survey. Trends in contraceptive use were examined. Multivariate analyses were conducted to identify characteristics associated with reliable contraceptive use (IUD use or consistent oral contraceptive use) in 1994 and 2003.

RESULTS

In each year, about 25% of sexually active women had used no contraceptive method in the past month, and 20% had used traditional methods. Prevalence of barrier method use increased from 9% to 21% between 1994 and 2003, while that of IUD use declined from 34% to 21%. These changes were especially pronounced in Moscow and St. Petersburg, and among younger women. Common reasons for nonuse were irregular sexual relations (cited by 29% of nonusers in 2003), desire for pregnancy (22%), perceived inability to get pregnant (15%), feeling that contraceptives are uncomfortable or unpleasant (15%), health problems (11%) and the availability of abortion (6%). In 1994 and 2003, the odds of reliable contraceptive use were elevated among women with at least a secondary education (odds ratios, 1.5-1.7), and were reduced among smokers (0.6-0.7).

CONCLUSIONS

Modern, effective contraceptive use has not increased among sexually active Russian women. Growing use of barrier contraceptives may reflect HIV awareness. Obstacles to effective contraceptive use, such as attitudes and health service factors, need further clarification.

Trends in levonorgestrel emergency contraception use, births, and abortions: the Utah experience

CONTEXT

Published reports to date have failed to demonstrate a decrease in abortion rates with increased dispersal of levonorgestrel emergency contraception (LNG EC).

OBJECTIVE

To evaluate whether there is an association between statewide increases in LNG EC use and birth, fertility, and abortion rates.

DESIGN

Ecological study. The number of LNG EC doses dispensed at all Planned Parenthood Association of Utah (PPAU) sites (n = 6) were obtained for 2000-2006. For this time period, birth and abortion data were obtained from the Utah Department of Health.

SETTING

State of Utah.

PATIENTS

Women of childbearing age.

MAIN OUTCOME MEASURES

Birth rates were calculated as the number of live births per 1000 population; general fertility rates, abortion rates, and LNG EC rates were calculated per 1000 women of childbearing age (15-44 years).

RESULTS

Between 2000 and 2006, yearly distribution of LNG EC increased from 11,263 to 52,083 doses. Over this period, the rate of Plan B use per 1000 women age 15-44 years increased from 21.30 doses/1000 to 87.82 doses/1000, an increase of 312%. During the same period, there were corresponding changes in the statewide birth rate (-2.94%), general fertility rate (0.73%), and abortion rate (-6.36%). Pearson correlation coefficients were statistically significant for the association between the LNG EC rate and the birth rate (-0.9053; P = .0050) and the abortion rate (-0.8749; P < .001), but not between the Plan B rate and the general fertility rate (0.2446; P = .5970).

CONCLUSION

This ecological study represents, to the authors' knowledge, the first statistically significant association between increasing rates of LNG EC distribution and decreasing abortion rates.

Abortion in Thailand and Sweden: health services and short-term consequences

In Thailand, where abortion is still illegal, abortion services (health services) outside Bangkok, and outside hospitals or clinics, are provided by non-physician practitioners. In the studies reported here, those practitioners were interviewed in 1978 and 1981 about their methods and the characteristics of their clients. The first study revealed that massage is the method most widely used by rural practitioners and that uterine injection with different solutions comes second. The second study was in agreement with these findings. The health consequences of these induced abortions were studied by interviewing the clients of the rural practitioners in 1980 and 1981. In Sweden, where abortion has been legal for quite a long time, all women who need an abortion have access to safe and convenient health services throughout the country.

Abortion in the United States: incidence and access to services, 2005

CONTEXT

Accurate information about abortion incidence and services is necessary to monitor levels of unwanted pregnancy and women's ability to access abortion services.

METHODS

All known abortion providers in the United States were contacted for information about abortion services in 2004 and 2005. This information, along with data from the U.S. Census Bureau, was used to examine national and state trends in numbers of abortions and abortion rates, proportions of counties and metropolitan areas without an abortion provider, and accessibility of abortion services.

RESULTS

An estimated 1.2 million abortions were performed in the United States in 2005, 8% fewer than in 2000. The abortion rate in 2005 was 19.4 per 1,000 women aged 15-44; this rate represents a 9% decline from 2000. There were 1,787 abortion providers in 2005, only 2% fewer than in 2000. Some 87% of U.S. counties, containing 35% of women aged 15-44, did not have an abortion provider in 2005. Early medication abortion, offered by an estimated 57% of known providers, accounted for 13% of abortions (and for 22% of abortions before nine weeks' gestation). The average amount paid for an abortion at 10 weeks was $413-after adjustment for inflation, $11 less than in 2001.

CONCLUSION

The numbers of abortions and the abortion rate continued their long-term decline through 2005. Reasons for this trend are unknown but may include improved access to and use of contraceptives or decreased access to abortion services.

Abortion rates and the role of family planning: a presentation of the Greek reality

OBJECTIVE

Due to lack of consistent evidence, it is widely believed that Greece holds one of the highest abortion rates in Europe. The aim of this study is to clarify these rates.

STUDY DESIGN

The Greek Society of Obstetrics and Gynecology collected data demonstrating that abortion rates seem to be declining which coincides with the rise of the use of more effective methods of contraception. Data were collected both from public and private hospitals, and an attempt was made to correlate the data with the current trends of family planning and birth control.

RESULTS

A decline in abortion rates in Greece was found, which may be due to the better organization of counseling programmes in the field.

CONCLUSION

The programmes organized by the Greek Family Planning Association under the guidance of the University of Athens has led to a decline in abortion rates in Greece.

Predictors of abortion provision among practicing obstetrician-gynecologists: a national survey

OBJECTIVE

The objective of the study was to identify the factors that predict whether physicians include pregnancy termination in their practices.

STUDY DESIGN

We surveyed all 5055 obstetrician-gynecologists who became board certified between 1998 and 2001 about personal characteristics, career plans, intention to provide abortions before residency, residency training, and current abortion practice.

RESULTS

Of 2149 respondents (43%), 22% had provided elective abortion in the past year. In multivariate analysis controlling for preresidency intentions, personal beliefs, and other variables, the following were independently associated with current abortion provision: completing a residency program with abortion training (odds ratio [OR], 1.6; confidence interval [CI], 1.1-2.3; P = .007) and performing a greater number of abortions during residency (>25 abortions: OR, 2.8; CI, 1.9-4.1; P < .001). Factors negatively associated with working in a practice (OR, 0.4; CI, 0.2-0.6; P < .001) or hospital (OR, 0.4; CI, 0.3-0.6; P < .001) that prohibits abortion.

CONCLUSION

Regardless of intention to provide abortion before residency, abortion training availability was positively correlated with providing abortion in future practice.

Abortion round the world

In the recent UK debates about the upper time limit for termination of pregnancy, attention focused on the number of abortions since legalisation. But, as Hannah Brown reports, rates of abortions have been falling faster in Western countries than elsewhere

Induced abortion: estimated rates and trends worldwide

BACKGROUND

Information on incidence of induced abortion is crucial for identifying policy and programmatic needs aimed at reducing unintended pregnancy. Because unsafe abortion is a cause of maternal morbidity and mortality, measures of its incidence are also important for monitoring progress towards Millennium Development Goal 5. We present new worldwide estimates of abortion rates and trends and discuss their implications for policies and programmes to reduce unintended pregnancy and unsafe abortion and to increase access to safe abortion.

METHODS

The worldwide and regional incidences of safe abortions in 2003 were calculated by use of reports from official national reporting systems, nationally representative surveys, and published studies. Unsafe abortion rates in 2003 were estimated from hospital data, surveys, and other published studies. Demographic techniques were applied to estimate numbers of abortions and to calculate rates and ratios for 2003. UN estimates of female populations and livebirths were the source for denominators for rates and ratios, respectively. Regions are defined according to UN classifications. Trends in abortion rates and incidences between 1995 and 2003 are presented.

FINDINGS

An estimated 42 million abortions were induced in 2003, compared with 46 million in 1995. The induced abortion rate in 2003 was 29 per 1000 women aged 15-44 years, down from 35 in 1995. Abortion rates were lowest in western Europe (12 per 1000 women). Rates were 17 per 1000 women in northern Europe, 18 per 1000 women in southern Europe, and 21 per 1000 women in northern America (USA and Canada). In 2003, 48% of all abortions worldwide were unsafe, and more than 97% of all unsafe abortions were in developing countries. There were 31 abortions for every 100 livebirths worldwide in 2003, and this ratio was highest in eastern Europe (105 for every 100 livebirths).

INTERPRETATION

Overall abortion rates are similar in the developing and developed world, but unsafe abortion is concentrated in developing countries. Ensuring that the need for contraception is met and that all abortions are safe will reduce maternal mortality substantially and protect maternal health.

Contraception and abortion

This article is the fourth in a series of articles on sexuality and sexual health.