The health dangers of unsafe abortion

Induced abortion is a safe medical procedure when carried out by skilled practitioners in hygienic environments.

In places with restrictive abortion laws, untrained providers, unsanitary conditions and limited access to high quality abortion services, women are much more likely to experience immediate complications, long-term disabilities or sometimes death. The harm caused by unsafe abortion practices is largely preventable.

Immediate complications from unsafe abortions include severe bleeding, uterine perforation, tearing of the cervix, severe damage to the genitals and abdomen, internal infection of the abdomen and blood poisoning. Medium and long-term complications range from reproductive tract infections (RTI) and pelvic inflammatory disease (PID) to chronic pain and infertility: 20 to 30 percent of unsafe abortions may lead to RTI, and of these, 20 to 40 percent result in PID and infertility. Late complications include increased risk of ectopic pregnancy, miscarriage or premature delivery in subsequent pregnancies.

South Africa liberalised its abortion law in 1996 and authorised trained midwives to perform induced first trimester abortion in public health facilities. Deaths from abortion complications decreased by 91 percent from 1994 to 2001. These changes provide an incentive for reforms in other countries.

Factors that influence the severity of complications and health outcomes include:

• Serious complications are much more likely when unsafe abortion occurs in late pregnancy. Studies in public hospitals in Kenya and South Africa found that over one third of patients seeking treatment for abortion complications presented after a second trimester abortion, when complication rates are higher than in the first trimester.
• Abortions induced by traditional practitioners or self-induced by women pose the greatest risk. However, women's increasing use of misoprostol – a prostaglandin (an 'abortion pill') available in pharmacies – is associated with lower rates of complications. Misoprostol is mainly used in Latin America, but use is expanding in other regions.
• Delays in reaching care after an unsafe abortion contribute to increased complications and high mortality.

Lessons for policy include:

• Trained midwives are as safe and effective as physicians in providing first trimester induced abortion with manual vacuum aspiration.
• Medical abortion is a recommended alternative to first trimester abortion.
• For abortions after 12 weeks, preferred options include dilation and evacuation, mifepristone, followed by repeated doses of a prostaglandin, or prostaglandins alone.
• Services offered at the lowest level of the health care system and close to women's homes offer the best prospects for rapid diagnosis, treatment and referral of abortion complications.
• Women seeking treatment for complications need to receive rapid, high quality care upon arrival at a health facility.

Janie Benson
Ipas, PO Box 5027, Chapel Hill, NC 27514, USA
bensonj@ipas.org

Marcel Vekemans
International Planned Parenthood Federation, Central Office, 4 Newham's Row, London, SE1 3UZ, UK
mvekemans@ippf.org

See also

'Unsafe Abortion: The Preventable Pandemic', The Lancet 368, pages 908-919, by David A. Grimes, Janie Benson, Susheela Singh, Mariana Romero, Bela Ganatra, Friday E. Okonofua and Iqbal H. Shah, 2006
www.thelancet.com/journals/lancet/article/PIIS0140673606694816/fulltext

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