Unsafe Abortion Around the World

Of the 46 million abortions that occur each year, roughly 20 million are performed under unsafe conditions because of poorly trained providers, unsanitary circumstances, and crude and dangerous methods of self-inducement. Each year, an estimated 80,000 women die from complications of unsafe abortion, accounting for at least 13 percent of global maternal mortality. The vast majority of these deaths are preventable. Unsafe abortion also causes long-term health problems that range from chronic pelvic pain to infertility (AGI, 1997; WHO, 1998a; AGI, 1999).

Women often choose abortion when faced with an unwanted pregnancy. Unplanned and unwanted pregnancies are a fact of life. They occur for a number of reasons: failure to use contraception; lack of access to family planning information and supplies because of political or economic circumstances; pressure from a sexual partner to not use contraceptives; contraceptive failure; and changes in circumstances that make a wanted pregnancy unwanted, such as abandonment, health problems, and financial difficulties (WHO, 1998a). In every society, across all religious, cultural, and economic differences, women face unplanned pregnancies as a result of trying to negotiate the difficult balance between having sexual relations and choosing whether and when to have children.

As long as there are unplanned and unwanted pregnancies, abortion will be a fact of life. When a woman decides to end an unwanted pregnancy, she will often go to extreme lengths to do so, regardless of whether the procedure is safe or legal. The rates at which women seek abortion are strikingly similar for women living in developed and developing countries (AGI, 1999). However, the chances of receiving a safe abortion vary widely and are determined by a variety of socioeconomic, legal, and cultural factors.

The Scope of Unplanned Pregnancy

Globally, nearly four in 10 pregnancies are unplanned (AGI, 1999). Many unplanned pregnancies result from the nonuse of contraceptives or from contraceptive failure. Couples may not use contraceptives because of traditional cultural beliefs and/or stigmas associated with particular methods. The World Health Organization estimates that between eight and 30 million unplanned pregnancies are the result of inconsistent or incorrect use of contraceptive methods, or from method-related failure (WHO, 1998a).

The Unmet Need for Family Planning

The sheer number of unplanned pregnancies — about 80 million each year — illustrates the enormous unmet need for family planning. Currently, 350 million couples around the world lack access to information about contraception and to modern methods of family planning. Between 120 and 150 million married women want to limit or space their pregnancies but lack the information and services to do so (WHO, 1998a; AGI, 1999).

How Many Women Undergo Abortion?

Each year, 46 million women around the world undergo abortion. Twenty-six million women who undergo abortion do so in countries with liberal abortion laws. The remaining 20 million undergo abortion in countries where abortion is either restricted or illegal (AGI, 1999).

Why Do Women Choose Abortion?

The reasons that women cite for choosing abortion are broadly similar throughout the world: Women may want to stop or postpone childbearing. They may have socioeconomic reasons for ending a pregnancy — they may not be able to afford the costs of having and raising a child, or they may want to continue pursuing their educational and career goals. Others may choose abortion because of relationship problems or because their pregnancy is the result of rape or incest. And still others may cite age or health reasons — they feel too young or too old to have a baby or that pregnancy will affect their own or their baby’s health (AGI, 1999).

Factors that Determine the Safety of Abortion

When performed by trained providers in sanitary conditions, abortion is one of the safest medical procedures. But for many women, abortion can be cost-prohibitive, and trained providers can be hard to come by. Because of these limitations, a woman may delay getting an abortion until later in her pregnancy when the risk of complications rises.

In developing countries, regardless of the legal status of abortion, poor women in rural areas are at most risk of undergoing unsafe abortion. Trained providers may not be available or affordable. Women might choose to go to traditional practitioners or to self-induce abortion. Many of the methods used are based on cultural or traditional practices — prolonged, hard massage of the abdomen; repeated blows to the abdomen; insertion of stones, twigs, or sharp wire objects into the vagina and cervix; drinking or flushing the vagina with caustic substances, for example (AGI, 1999).

The Scope of Unsafe Abortion

Every day, 55,000 unsafe abortions take place — 95 percent of them in developing countries (WHO, 1998a). Worldwide, the maternal mortality rate due to unsafe abortion is 0.4 per 100 unsafe abortions. The highest rates occur in the developing world — 0.6 in Africa and 0.4 in Asia ( Mundigo & Indriso, 1999).

In the developed world, the risk of dying from an unsafe abortion is one in 3,700 procedures (Mundigo & Indriso, 1999), but in Europe (primarily Eastern Europe) the risk is one in 1,900 procedures. In Latin America and the Caribbean the risk is one in 900 procedures, in Asia (excluding Japan, Australia, and New Zealand) it is one in 250, and in Africa it is one in 150 (WHO, 1998a; WHO, 1998b).

Another way to look at this disparity is to note overall death rates from abortion (whether safe or unsafe): in the developed world there are 0.2–1.2 maternal deaths per 100,000 abortions, whereas in the developing world (excluding China) the rate soars to 330 maternal deaths per 100,000 abortions. In Africa the rate is 680 per 100,000 abortions, in South and Southeast Asia it is 283, and in Latin America it is 119 per 100,000 abortions (AGI, 1999).

Because of anti-abortion social stigma and/or poverty, in the developing world, it is unsafe abortion, either self-induced or performed by an unqualified abortionist, that non-married adolescent girls most often seek — regardless of whether or not abortion is legal in their country. Because adolescents often seek unsafe abortions and because they tend to wait to seek abortion later than do older women, they are at greater risk of complications. Teenagers comprise a significant proportion of victims of unsafe abortion. A study done in Tanzania found that nearly a third of the victims of unsafe abortion were teenagers, of whom almost half were 17 years of age or younger; about one in every four were students in primary or secondary school. A safe procedure is very expensive in Tanzania and, therefore, unaffordable for most non-married young women there (Mundigo & Indriso, 1999; Mpangile et al., 1999).

Restrictive legislation is associated with higher rates of unsafe abortion and correspondingly high mortality. In Romania, for example, abortion-related deaths increased sharply when the law became very restrictive in 1966 and fell after 1990 with a return to the less restrictive legislation (WHO, 1998a).

Complications Resulting from Unsafe Abortion

The World Health Organization estimates that between 10 and 50 percent of women who undergo unsafe abortion have complications (WHO, 1998a). The most common complications are incomplete abortion, tears in the cervix, perforation of the uterus, fever, infection, septic shock, and severe hemorrhaging. It is estimated that 80,000 women die each year due to complications from unsafe abortion (WHO, 1998a). However, the actual number of deaths may be much greater because women who die outside of hospitals or in emergency wards may not have autopsies performed, and may not be identified as victims of unsafe abortion. (Mpangile, et. al, 1999; Paxman, et. al, 1993). Other serious long-term health consequences faced by women who have unsafe abortions include chronic pelvic pain, problems getting and staying pregnant, infertility, tubal blockage, and ectopic pregnancy (AbouZahr & Åhman, 1998).

Treatment of Complications from Unsafe Abortion

Whether a woman receives appropriate medical care for complications resulting from unsafe abortion depends largely on the proximity and availability of emergency facilities and trained health providers. Social, cultural, legal, and economic barriers may prevent women from accessing treatment as well. While most urban centers have hospitals, many poor women in rural areas simply don’t have access to medical treatment when faced with complications. Treatment can be costly as it may require hospitalization, staff time, antibiotics, and blood transfusions.

How to Prevent Unsafe Abortion?

At the 1994 International Conference on Population and Development (ICPD), the world’s nations agreed that unsafe abortion is a major public health concern, and that governments should work to eliminate unsafe abortion and make abortion safer in countries where it is legal (UN, 1994; WHO, 1998a). Eliminating unsafe abortion requires an integrated, comprehensive approach involving health workers, policymakers, and advocates. Societies must

• ensure high-quality, compassionate treatment for complications resulting from unsafe abortion that includes post-abortion and family planning counseling
• provide universal access to family planning
• reform restrictive laws and policies that hinder the availability of safe services and trained providers
• ensure safe abortion services

References and Additional Information

AbouZahr, Carla & Elizabeth Åhman. (1998). "Unsafe Abortion and Ectopic Pregnancy." Pp. 267-296 in Christopher J.L. Murray & Alan D. Lopez, eds., Health Dimensions of Sex and Reproduction: The Global Burden of Sexually Transmitted Diseases, HIV, Maternal Conditions, Perinatal Disorders, and Congenital Anomalies. Cambridge, MA: Harvard School of Public Health on behalf of the World Health Organization and the World Bank.

AGI — Alan Guttmacher Institute. (1997). Issues in Brief: The Role of Contraception in Reducing Abortion. New York: Alan Guttmacher Institute.

_____. (1999). Sharing Responsibility: Women, Society, and Abortion Worldwide. New York: Alan Guttmacher Institute.

Mpangile, G.S., et al. (1999). "Induced Abortion in Dar es Salaam, Tanzania: The Plight of Adolescents." In Axel I. Mundigo & Cynthia Indriso, eds., Abortion in the Developing World. London, England: Zed Books.

Mundrigo, Axel I. & Cynthia Indriso, eds. (1999). Abortion in the Developing World. London, England: Zed Books.

Paxman, John, et al. (1993). "The Clandestine Epidemic: The Practice of Unsafe Abortion in Latin America." Studies in Family Planning, 24, 205–224.

UN — United Nations. (1994). Report of the International Conference on Population and Development (Cairo, 5–13 September 1994).

WHO — World Health Organization. (1998a, accessed 2000, June 16). World Health Day/Safe Motherhood, 7 April 1998: Address Unsafe Abortion (WHD 98.10) [ Online] . http://www.who.int/archives/whday/en/pages1998/whd98_10.html

_____. (1998b, accessed 2000, June 16). Safe Motherhood Fact Sheet: Unsafe Abortion [ Online] . http://www.safemotherhood.org/facts_and_figures/unsafe_abortion_fact.htm

Courtesy Planned Parenthood Federation of America, Inc.