Editorial

The high cost of unsafe abortion

Every eight minutes a woman dies somewhere in a developing country due to complications from an unsafe abortion. She most likely had little money or support to obtain safe services. She probably first tried to induce a termination herself. Failing that she would have turned to an unskilled, but relatively inexpensive, provider.

The cost of unsafe abortion-related ill-health and death was the subject of a technical meeting held at the Institute of Development Studies (UK) on 18 and 19 April 2007. It was funded by the Hewlett Foundation and brought together experts on unsafe abortion and economists specialising in costing methods. The meeting reviewed recent work estimating the cost of unsafe abortion to the health sector. Participants also discussed the economic costs to health systems, individuals and households, and the links between unsafe abortion and poverty. This issue of id21 health focus highlights the findings reviewed at the meeting and points to important lessons for decision-makers.

Unsafe abortion carried out by individuals lacking the necessary skills and/or in unhygienic conditions, is a major global public health problem. The practice occurs where abortion is legally restricted, and where access to safe services is inadequate although the law may broadly permit the procedure. Unsafe abortion causes death and ill health in women, and burdens households, health systems and society.

Each year, there are an estimated 19 million unsafe abortions worldwide, most in low-income countries. About 5.2 million of these women are hospitalised for serious complications, while an unknown but possibly equal number of women suffer similarly serious complications but cannot obtain treatment. As a result, around 68,000 women die each year, making unsafe abortion a significant cause of maternal mortality. This number has remained unchanged since 1990.

Number of reported unsafe abortions per 1,000 women aged 15 – 44 years, 2000
(Larger version)

In 2000, the consequences of unsafe abortion were greater in Africa than in Asia and Latin America. In Africa, 709 women die per 100,000 unsafe abortions, compared to 324 in Asia and 100 in Latin America. Nearly half of all deaths due to unsafe abortion occur in Africa, although Africa accounts for only 13 percent of all women of reproductive age in developing countries.

Abortion service provision is changing

In recent years, countries such as Nepal have responded by liberalising their abortion law. When accompanied by expanded access to safe services, as in South Africa, this greatly reduces complications and deaths from unsafe abortion. Another promising trend is the increased use of new drugs such as mifepristone and misoprostol – the 'abortion pill' – in very early pregnancy. These are an effective alternative to surgery and further reduce the risk and severity of complications.

Key policy lessons that emerged from the workshop include:

• Women need better access to contraceptive information and services to reduce unintended pregnancies and abortion (unsafe and safe).
• Where the law broadly permits abortion, safe services need to be expanded so that women do not need to resort to unsafe methods.
• Where the law is highly restricted, access to services for permitted criteria should be provided. Advocacy should highlight the unacceptable cost of unsafe abortion and the benefits of expanding the criteria for legal abortion.
• The quality and coverage of post-abortion care in developing countries need urgent improvement.

Susheela Singh
Guttmacher Institute, 120 Wall Street, New York, NY, 10005, USA
T +1 212 248 1111 (ext 2264)
ssingh@guttmacher.org

Iqbal H. Shah
UNDP/UNFPA/WHO/World Bank Special Programme in Human Reproduction, World Health Organization, 1211 Geneva 27, Switzerland
T +41 22 7913332
shahi@who.int

Hilary Standing
Realising Rights Research Programme Consortium, Institute of Development Studies, University of Sussex, Brighton, BN1 9RE, UK
H.Standing@ids.ac.uk

See also

Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2000, Geneva: World Health Organization, 2004
www.who.int/reproductive-health/publications/unsafe_abortion_estimates_04/estimates.pdf

Sharing Responsibilities: Women Society and Abortion Worldwide, New York: The Alan Guttmacher Institute, 1999
www.guttmacher.org/pubs/sharing.pdf

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