Abortion laws reform may reduce maternal mortality: an ecological study in 162 countries

BACKGROUND

Unsafe abortion is one of the commonest causes of maternal mortality. Abortion-related maternal deaths are higher in countries with the most restrictive abortion laws. We assess whether maternal mortality varies within and between countries over time according to the flexibility of abortion laws (the number of reasons a woman can have an abortion).

METHOD

We conducted an ecological study to assess the association between abortion laws and maternal mortality in 162 countries between 1985 and 2013. Aggregate-level data on abortion laws and maternal mortality were extracted from United Nations (UN), and World Health Organization's (WHO) database respectively. A flexibility score of abortion laws (Score 0-7) was calculated by summing the number of reasons for which abortion was legally allowed in each country. The outcome was maternal mortality ratio (MMR), which represented maternal deaths per 100,000 live births. MMR was modelled as a continuous variable and flexibility score as an ordinal ranked variable (categories 0-7 with 0 as the reference, and < 3 vs > = 3). We used fixed effects linear regression models to estimate the association between flexibility score and MMR, adjusting for gross domestic product per capita (GDP per capita), and time in five-year intervals.

RESULTS

Compared to when a country's flexibility score was < 3, maternal deaths were reduced by 45 per 100,000 live births (95% CI: -64, - 26) when the flexibility score increased ≥3, after adjusting for the GDP per capita and five-year time intervals. With the exception of a flexibility score 6, MMR was lower when higher than zero. This may indicate the role of other country- specific effects.

CONCLUSION

This study provides evidence that abortion law reform in countries with restricted abortion laws may reduce maternal mortality.

A question of choice

Women's reproductive rights, reproductive health, and constitutional privacy rights in the United States are addressed in light of the contemporary onslaught of the Christian Right. The misuse of State power by fundamentalist social forces in America is critiqued. The article also briefly reviews the question of State control over women's bodies.

The magnitude of abortion complications in Kenya

OBJECTIVE

To estimate and describe the magnitude of abortion complications presenting at public hospitals in Kenya.

DESIGN

Cross-sectional descriptive study.

SETTING

Hospital-based. Population Records of all women presenting prior to 22 weeks of gestation with abortion-related complications at selected hospitals during a three-week study period. All public tertiary and provincial hospitals were included; stratified random sampling was employed to select a subset of 54 district hospitals nationwide.

METHODS

Data collectors identified 809 patients with abortion complications on all hospital wards and completed a standardised questionnaire for each by extracting information from the patient's hospital record.

MAIN OUTCOME MEASURES

Incidence, aetiology, morbidity and mortality of abortion complications.

RESULTS

Most women (80%) presented with incomplete abortion. Approximately 34% of the women had reached the second trimester of pregnancy. Adolescents (14-19 years old) accounted for approximately 16% of the study sample. Manual vacuum aspiration was used to manage 80% of first trimester cases. The projected annual number of women with abortion complications admitted to public hospitals in Kenya is 20,893. The case fatality rate was estimated to be 0.87% (95% CI 0.71-1.02%), so an estimated 182 (95% CI 148-213) of these women die annually. The annual incidence of incomplete abortion and other abortion-related complications per 1000 women aged 15 to 49 years is projected to be 3.03.

CONCLUSIONS

The high rate of abortion-related morbidity and mortality documented in the study highlights the critical need to address the issue of unsafe abortion in Kenya.

Medical abortion in social context

Early medical abortion regimens, especially those that include mifepristone, have the potential to reshape the landscape of abortion provision in the United States. Because medical abortion does not require surgical training, it may attract new providers of abortion services from a variety of specialties, including advanced practice clinicians. The diffusion of abortion services into myriad clinical and office-based settings may reduce the violence that has been associated with abortion provision. However, a number of factors may slow the spread of medical abortion, at least initially. These factors include the need for accurate means to date early pregnancies, the need to arrange backup surgical services for the small number of patients who require them, the obligation to conform to existing legal mandates governing surgical abortion, and possible difficulties negotiating appropriate malpractice coverage and reimbursement. Educational initiatives are needed to help clinicians to overcome these barriers and to actualize mifepristone's potential in women's health care.

A chill wind blows: Webster, obstetrics, and the health of women

The Supreme Court decision in Webster v Reproductive Health Services permits states to regulate abortion in fashions that may be medically unsound and may significantly restrict access. This decision challenges the contemporary practice of obstetrics and threatens to curtail access to needed services, particularly for poor women, who are at highest risk of pregnancy-associated medical complications and death. Governmental restrictions on abortion interfere with the obstetrician's basic goal of providing optimal care for the patient. Obstetricians dedicated to providing the best care to their patients should help to ensure that safe abortion be part of a spectrum of reproductive health care that is available to all American women.