A C TA Obstetricia et Gynecologica

ACTA OVER V I E W

Unsafe abortion and postabortion care an overview

VIBEKE RASCH
Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark

Key words Abortion method, complications, law, postabortion care, unsafe abortion Correspondence Vibeke Rasch, Department of Obstetrics and Gynaecology, Odense University Hospital, DK-5250 Odense, Denmark. E-mail: vrasch@health.sdu.dk Conict of interest The author has stated explicitly that there are no conicts of interest in connection with this article. Received: 15 November 2010 Accepted: 18 April 2011 DOI: 10.1111/j.1600-0412.2011.01165.x

Abstract Forty per cent of the worlds women are living in countries with restrictive abortion laws, which prohibit abortion or only allow abortion to protect a womans life or her physical or mental health. In countries where abortion is restricted, women have to resort to clandestine interventions to have an unwanted pregnancy terminated. As a consequence, high rates of unsafe abortion are seen, such as in Sub-Saharan Africa where unsafe abortion occurs at rates of 1839 per 1 000 women. The circumstances under which women obtain unsafe abortion vary and depend on traditional methods known and types of providers present. Health professionals are prone to use instrumental procedures to induce the abortion, whereas traditional providers often make a brew of herbs to be drunk in one or more doses. In countries with restrictive abortion laws, high rates of maternal death must be expected, and globally an estimated 66 500 women die every year as a result of unsafe abortions. In addition, a far larger number of women experience short- and long-term health consequences. To address the harmful health consequences of unsafe abortion, a postabortion care model has been developed and implemented with success in many countries where women do not have legal access to abortion. Postabortion care focuses on treatment of incomplete abortion and provision of postabortion contraceptive services. To enhance womens access to postabortion care, focus is increasingly being placed on upgrading midlevel providers to provide emergency treatment as well as implementing misoprostol as a treatment strategy for complications after unsafe abortion.

Introduction
Maternal mortality and morbidity are the leading causes of death and illness among women of reproductive age in many countries throughout the world. Efforts to reduce maternal deaths have been high on the political agenda for many years and progress has been made, as indicated in a recent study reporting a drop in maternal deaths from roughly 525 000 in 1980 to about 343 000 in 2008 (1). In spite of these encouraging ndings, there is a widespread perception that the decrease in maternal mortality is too slow and that the target for the Millennium Development Goal 5, a 75% reduction in the maternal mortality ratio from 1990 to 2015, will not be reached (2). Of all maternal deaths, those related to unsafe abortion are the most severely underestimated and yet at the same time they are those which are the most preventable (3). However, increased use of medical abortion owing to enhanced access to misoprostol in lowincome settings as well as increased provision of abortion

by trained personnel have probably led to a decline in the severity of complications from unsafe abortion during recent years (4). Unsafe abortion is dened as a termination of an unintended pregnancy by persons lacking the necessary skills, or in an environment lacking the minimum medical standards, or both (3). Globally, unsafe abortions account for 13% of all maternal deaths and contribute to signicant morbidity among women, especially in under-resourced settings. Factors which contribute to the problem of unsafe abortion include restrictive abortion legislation, inadequate contraceptive services and poor health-service infrastructure (4). By addressing these factors, many maternal deaths could be prevented. This article focuses on unsafe abortion and describes how restrictive laws are associated with the occurrence of unsafe abortion. It describes providers and methods used to obtain unsafe abortion and the associated health consequences. Finally, postabortion care as a means to address the problem of unsafe abortion is presented and discussed.

692

Acta Obstetricia et Gynecologica Scandinavica

C 2011 The Author 2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 692700

V. Rasch

Unsafe abortion and postabortion care

Material and methods

Owing to the legal circumstances surrounding unsafe abortion, the topic of this article was not considered appropriate for a rigorous systematic review. However, a systematic search in PubMed, covering January 2005 to October 2010, was performed to identify publications on unsafe abortion rates, unsafe abortion methods, health consequences and postabortion care. Primary search terms, together with the number of retrieved articles in parentheses, were as follows: clandestine abortion (22), unsafe abortion rate (160), unsafe abortion incidence (95), unsafe abortion provider (10), unsafe abortion method (127), unsafe abortion deaths (38), unsafe abortion complications (89), unsafe abortion postabortion care (32), postabortion contraception (38), incomplete abortion misoprostol (71) and abortion manual vacuum aspiration (64). A total of 746 publications were identied, including both original articles and reviews, whereas hardly any randomized control trials were identied. The search results showed a signicant overlap for these terms, and of the 746 identied publications, 404 were found to be duplicates and thus excluded. This exclusion left 342 original articles and reviews to be further assessed for their relevance for the present review. From the titles and the abstracts, 186 of the 342 articles were excluded because they were written in a language other than English (French, Spanish, Portuguese, Dutch or Russian), because they were focusing on secondtrimester abortion or because they were not classied as scientic articles. Reference lists of the 156 articles identied by this strategy were also searched and assessed for their relevance to the predened themes (abortion laws, abortion rate, abortion providers and methods, health consequences, manual vacuum aspiration, misoprostol and postabortion contraception), and nine additional publications were identied. Thus, in all, 166 publication were judged relevant and included in the initial review. The full text of all publications included in the initial review was retrieved and assessed for methodological quality, which involved assessment of study design, features of study population, data collection method and ndings. Based on this assessment, it was decided to base the nal review on 67 publications considered to be of high scientic standard as well as of high relevance for the topic studied. The included studies have used different denominators to calculate abortion rate; some studies report abortion rate per 1 000 women aged 1544 years and others per 1 000 women aged 1549 years. This difference may have had an impact on the reported abortion rate in the different populations; however, as the number of women aged 4549 years who experience an unsafe abortion is small in all populations, it is believed that the gures are still comparable. In this overview, abortion rate is dened as number of abortions per 1 000 women of reproductive age, bearing in
26% 39% 10% 4% 21%

To save life or prohibited To preserve physical health To preserve mental health Socioeconomic grounds Without restriction

Figure 1. Countries, by restrictiveness of abortion law, 2009.

mind that in some of the reports the denominator is women aged 1544 and in others 1549 years.

Results
Abortion laws and unsafe abortion rates
The wide range of laws governing the practice of induced abortion around the world is shown in Figure 1, which classies the laws of 197 countries into ve categories (to save a womans life or prohibited altogether, to preserve physical health, to preserve mental health, socioeconomic grounds and no restriction). In 68 countries, abortion is not legally permitted on any grounds or only to save the womans life, and 26% of the worlds population are living in countries with such restrictive laws (5). In 36 countries, home to 10% of the worlds population, abortion is allowed only to protect a womans physical health and in another 23 countries, home to 4% of the worlds population, also to protect her mental health. Finally, 21% of the worlds population lives in the 14 countries that permit abortion on socioeconomic grounds and another 39% are living in the remaining 56 countries, where abortion is available without restriction as to indication, albeit not gestational length (5). Thus, around 40% of women of childbearing age (1544 years) live in countries with highly restrictive laws which prohibit abortion or only allow the procedure to save a womans life, or to protect her physical or mental health. In countries where restrictive abortion laws prevail, high rates of unsafe abortion must be expected. In Africa, where abortion is restricted in most countries, almost all abortions are performed unsafely and the rates of unsafe abortion vary from 18 to 39, being highest in Eastern Africa and lowest in Southern and Northern Africa (4). The comparatively low rate of unsafe abortion in the southern part of Africa reects a liberalization of the abortion law in 1995 (6). In Uganda, where abortion is only legally available to save the life of a woman, the estimated rate of unsafe abortion is 54 (7). This high abortion rate is likely to reect

C 2011 The Author Acta Obstetricia et Gynecologica Scandinavica

2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 692700

693

Unsafe abortion and postabortion care

V. Rasch

the fact that Ugandan women are having difcult access to contraception. In Latin America and the Caribbean, the vast majority of abortions are, like in Africa, performed unsafely, and the estimated rates of unsafe abortion are 1633 (4). For example, in Mexico, where abortion is only legally available to preserve physical health, the abortion rate was 33 in 2006 (8). Likewise, in Guatemala, although law permits induced abortion only to save a womans life, unsafe abortions occur at a rate of 24, and there is one abortion for every six births (9). In comparison, in the Caribbean, the unsafe abortion rate is estimated to be only 16, reecting that safe legal abortion is available in Cuba and therefore a comparatively lower number of women in this subregion have to resort to clandestine interventions (4). When focusing on Asia, the estimated rates of unsafe abortion are between 9 and 28 (4). For instance, in the Philippines, where abortion is prohibited altogether, 473 400 women had an unsafe abortion in 2000 and the rate of unsafe abortion was reported to be 27 (10). However, great differences between urban and rural Philippines have been documented, with unsafe abortion rates of 52 in metropolitan Manila and 17 in more rural parts of the country (10). Similar high abortion rates have been reported from Pakistan, where abortion is only legal to preserve the womans physical health. Hence, it has been estimated that 890 000 unsafe abortions are performed annually in Pakistan, being equal to an annual rate of 29 or about 37% of all pregnancies (11). The study further documented that the abortion rate was higher in provinces where contraceptive use is low and where unwanted childbearing is high. The above documented rates of unsafe abortion clearly illustrate that legal restrictions do not lower the incidence of abortion but rather increase the risk of unsafe abortion. Hence, high abortion rates prevail in countries where the procedure is legally restricted, whereas comparatively lower abortion rates of 1217 have been reported in, for example, western and northern Europe, where abortion is permitted on broad grounds (12).

Providers and methods

The circumstances under which women obtain unsafe abortion vary from one setting to another and depend on the traditional methods known, the types of providers present and the availability of trained health professionals who are willing to perform abortion despite the intervention being illegal. In a recent study from Pakistan, 80% of the women had terminations performed by health professionals, namely doctors, lady health visitors or nurses (13). A similar picture has been found in Burkina Faso, where 61% of all abortions were induced by a health professional (14). A Nigerian survey documented that women often resort to medical doctors, even if they want to have an unwanted pregnancy termi-

nated by a clandestine abortion. More specically, 90% of 323 Nigerian doctors interviewed stated they were frequently attended by pregnant women who requested a clandestine induced abortion and 24% reported that they did terminate unwanted pregnancies when requested to do so by the women (15). Other commonly used providers are traditional healers and traditional birth attendants. As documented in a Tanzanian study conducted among 469 women admitted with complications after an unsafe abortion, 60% of urban women and 47% of rural women had either induced the abortion themselves or had resorted to traditional providers (16). To obtain a broader picture of the situation, surveys of health professionals knowledge about the way in which unsafe abortions are carried out in their countries have been performed. The ndings clearly document that a womans choice of provider varies greatly in different settings. More specically, in Guatemala, a poor and mainly rural country, the use of traditional providers is high (49%), whereas in Mexico, a more afuent country, only 14% of the women resort to traditional providers to have an abortion (4). In Pakistan and Uganda, the involvement of health professionals is substantially higher than in Mexico and Guatemala (4). Hence, it is not just the wealth of the country which predicts whether women resort to traditional providers or health professionals for abortion. The womens choices of abortion providers are also associated with the country-specic culture and norms. Furthermore, health professionals often play a larger role in providing services for urban than for rural women, partly because they mostly work in urban areas, but also because urban women have higher family incomes, on average, than do rural women, making them better able to afford service provided by a health professional. This is the situation in Nigeria, where a national household-based survey found that poor women had a 2.4 times increased odds ratio of using a nonprofessional provider than nonpoor women (17). The method used to induce the abortion is closely linked with the providers professional background. For instance, in Tanzania it has been documented that traditional providers often make a brew of herbs and roots from local plants soaked in water, to be drunk in one or more doses (16). Another common method used by traditional healers is to induce the abortion by inserting a cassava stick in the uterine cervix (16,18). Likewise, a Ghanaian study has reported the use of herbs to be a common method used by traditional providers to terminate unwanted pregnancies (19). Health professionals who provide unsafe abortions are more prone to use instrumental procedures, such as a catheter or sound to induce the abortion. If it is a qualied person who has received training in surgical procedures, he or she may use either vacuum aspiration or dilatation and curettage to terminate the pregnancy (16,20). In addition to the traditional methods and the instrumental and surgical procedures, misoprostol has become
C 2011 The Author 2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 692700

694

Acta Obstetricia et Gynecologica Scandinavica

V. Rasch

Unsafe abortion and postabortion care

a method which is being used increasingly to induce abortion clandestinely (3,4,21). Owing to stigma associated with an unsafe abortion, women keep their pregnancy to themselves and only conde in close relatives and friends who may help by guiding them as to where to obtain a clandestine abortion (19,22,23). Women often try sequential abortion methods to terminate their pregnancy, starting with cheaper and less effective methods provided by traditional healers and if these attempts fail, the women resort to harsher and more expensive methods (4,19).

Health consequences of unsafe abortion

The vast majority of abortion-related deaths occur in SubSaharan Africa (about 36 000) and south Central Asia (about 28 400), whereas the number is negligible in southern and western Europe, North America and China (3). In Tanzania, a recent review of 113 maternal deaths suggested that 14 (12%) women had died following an unsafe abortion (24), while in Nigeria 1213% of maternal deaths have been reported to be due to unsafe abortion (25,26). The reported gures from Tanzania and Nigeria are in accordance with the global estimate of unsafe abortion accounting for 13% of all maternal deaths (3). However, there are great variations between regions and countries, and a recent study from Kenya, based on verbal autopsies, reported unsafe abortion to be responsible for 31% of all maternal deaths (27). Furthermore, in a hospital-based study from Ghana, the leading cause of maternal deaths was reported to be complications of abortion. This accounted for 7/24 (29%) of all maternal deaths (28), and in Malawi unsafe abortion has been documented to be responsible for 48/204 (24%) of all maternal deaths (29). Beyond the estimated 66 500 yearly maternal deaths from unsafe abortion, a far larger number of women experience short- and long-term health consequences. In a Nigerian study based on data from 586 patients admitted with abortion complications in 2002, the most common were infection (55%), bleeding (17%) and trauma to the genital tract (12%) (30). Less common but very serious complications are septic shock, renal failure, perforation of the intestines and peritonitis (31). Chronic pain, inammation of the reproductive tract and pelvic inammatory disease, which may lead to secondary infertility, are other common complications. Estimates based on the limited available data suggest that around 1.7 million women develop secondary infertility each year as a consequence of badly performed abortions, and more than three million annually experience reproductive tract infections that become chronic conditions (3). In countries with restrictive abortion laws, the health consequences of unsafe abortion are reected in the hospital statistics, which include signicant numbers of women admitted with abortion complications. In Tanzania, it has been
C 2011 The Author Acta Obstetricia et Gynecologica Scandinavica

documented that women suffering from complications after an unsafe abortion represent approximately 2025% of all gynecological admissions (16,32). The treatment of abortion complications in hospitals consumes a signicant share of resources, including hospital beds, blood supply, medications, and often operating theatres, anesthesia and medical specialists (33). In Nigeria, the average costs for women admitted with complications after an unsafe abortion were four times higher than for women who had a safe abortion within the hospital setting (30). Thus, the consequences of unsafe abortion place great demands on the scarce clinical, material and nancial resources of hospitals in many low-income countries where abortion is restricted by law.

Postabortion care
To address the harmful health consequences of unsafe abortion, a postabortion care model was developed in 1994 (34). The model lists three essential elements: (1) emergency treatment for complications of spontaneous or induced abortion; (2) postabortion family planning counseling and services; and (3) linkage between emergency care and other reproductive health services, such as management of sexually transmitted diseases. The postabortion care model has been implemented in many countries with restrictive abortion laws as a means to address the complications associated with unsafe abortion. It has proved to be an acceptable way to improve services provided to women postabortion without violating local norms or legal restrictions on the provision of abortion. When focusing on emergency treatment for abortion complications, manual vacuum aspiration (MVA) is considered a cost-effective alternative to standard surgical curettage, which is often used for emergency care in low-income settings. The efcacy of MVA has been assessed in a retrospective Scottish study, which reported the efcacy of the procedure to be 94.7% among 245 patients undergoing MVA for incomplete abortion (35). A meta-analysis has also measured the safety, efcacy and acceptability of MVA in comparison with electric vacuum aspiration. There was no signicant difference in complete abortion rate and participants satisfaction, whereas the operation time was shorter for electric vacuum aspiration (36). Manual vacuum aspiration is also well accepted for surgical uterine evacuation in low-income settings, as illustrated in a review of 10 major postabortion care projects conducted in Latin America in the period 19912002. It was found that the majority of patients were treated by this method as opposed to sharp curettage (37). However, the sustainability of the procedure has been questioned, and a situation analysis conducted in Ghana in 2007 revealed that despite consensus about the serious need for MVA in Ghana, the country lacked sustainable access to MVA (38). The main barriers reported were government restriction on procurement, high

2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 692700

695

Unsafe abortion and postabortion care

V. Rasch

cost of equipment, limited access to MVA training and lack of priority when facilities for access to funds were limited (38). Other studies have likewise reported that procurement and maintenance of MVA equipment is a challenge in many lowincome settings (39). Focus has also been placed on misoprostol as a means to increase womens access to postabortion care (40). Trials of the technique in Burkina Faso (41), Mozambique (42), Tanzania (43) and Uganda (44) have shown promising results of misoprostol being a satisfactory substitute for the treatment of incomplete abortion, and misoprostol is increasingly being considered as a method to address womens poor access to postabortion care. Hence, there is a growing consensus that misoprostol has the potential to achieve good treatment outcomes and save lives if made available for treatment of abortion complications at primary health facilities (45). However, despite misoprostol being on the list of essential medicines of the World Health Organization since 2005, the drug is still not available in many countries. To address this problem, Women on Web (WoW, www.womenonweb.org) help women to access medical abortion up to nine weeks of pregnancy in countries where there are no safe abortion services. The organization uses telemedicine to help women access mifepristone and misoprostol. After an online consultation, women with an unwanted pregnancy of up to nine weeks are referred to a doctor. If there are no contraindications, a medical abortion is conducted by mail. A review of the womens reports of the telecommunication service and the consequences experienced through self-administration of mifepristone and misoprostol for early abortion have recently been conducted among 249 women who had received the service. Fourteen reported undergoing a curettage/vacuum aspiration for an incomplete abortion or for excessive bleeding, 1% used antibiotics for an infection and 2% reported a continuing pregnancy (46). Based on the ndings, the authors concluded that telemedicine can provide an alternative to unsafe abortion in countries with restrictive abortion laws. Postabortion contraceptive counseling is considered an important means to avoid repeating the vicious cycle of unprotected intercourse, unwanted pregnancy and repeat unsafe abortion (47). The acceptance of postabortion contraceptive service has been documented in different studies. A recent cross-sectional study from Brazil reported a postabortion contraceptive acceptance rate of 97.4% (48). Comparatively lower rates of contraceptive acceptance have been reported from Cambodia, where 42% of abortion clients accepted postabortion contraception (49). The Cambodian study further reported that women who presented at facilities where a nurse/midwife managed abortion services, where contraceptives and abortions were provided in the same room and where a larger range of methods were offered had signicantly higher odds of postabortion contraceptive acceptance. Studies from Guatemala (50), Bolivia and Mexico (51) and

Tanzania (52) have likewise shown that contraception is well accepted when postabortion contraceptive services are implemented as part of emergency treatment.

Discussion
This overview is a summary of the most relevant literature related to unsafe abortion and postabortion care. Assessing the magnitude of the problem of unsafe abortion and its consequences is one of the least documented reproductive health problems and, not coincidentally, it is difcult to document. Focusing on the reported unsafe abortion rates, they are based on estimates and should thus be considered approximate measures. Women who have experienced unsafe abortion as well as the abortion providers are reluctant to report having had or having performed an abortion. In addition, governments do not collect data on abortions performed outside the legal health system. Although the quality of the methods used to estimate unsafe abortion rates have improved and it is believed that the estimates have become more reliable (4), the reported gures should be considered with some caution. Information about health consequences of unsafe abortion has mainly been obtained from women who have been hospitalized with abortion complications (3). An inherent weakness of this approach is that it does not cover women who have abortions in clandestine circumstances but experience no complications, nor does it cover women who experience complications but obtain no care (4). In addition, most of the studies have relied on a set of clinical criteria where the classication of unsafe abortion is based on the presence of infection/sepsis or trauma combined with the statement unplanned pregnancy (53). However, the use of sepsis as a criterion for classifying an abortion as induced depends on the assumption that infection risk is much higher after an induced than after a spontaneous abortion. Among women in low-income countries, the proportion of spontaneous abortions that result in localized infection or sepsis is unknown. If it is large, there may be substantial misclassication. In addition, pregnant women with febrile diseases such as malaria and a concomitant, spontaneous abortion may be misclassied for this reason. An alternative and perhaps more trustworthy approach would be to identify the women through an empathetic interview, which has proved to be an improvement of the clinical approach (54). The best way to reduce the health burden associated with unsafe abortion is a legal change of restrictive abortion laws which prevail worldwide. A lot of effort has been invested during the past years in advocating such law changes, and changes have occurred. Hence, during the period 19982007, 16 countries added indications that moved them from one category to another less strict category or recognized rape, incest or fetal impairment as grounds for legal abortion (55).
C 2011 The Author 2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 692700

696

Acta Obstetricia et Gynecologica Scandinavica

V. Rasch

Unsafe abortion and postabortion care

However, although liberalization of abortion laws and regulations has taken place all over the world, restrictions have also increased, and Poland and Lithuania are examples of countries which have taken a conservative path on abortion. In Poland, the abortion law was revised in 1993 to permit abortion only when a pregnancy threatens the womans life or health and a more liberal law enacted in 1996 was overturned by the Constitutional Court in 1997 (56). In Lithuania, a draft law, which has not yet been passed, bans abortion except in cases where the mothers health is in danger or if she conceived the child during sexual molestation (55). It should be born in mind that in countries where abortion is illegal, liberalization of induced abortion is a very sensitive issue. In Nigeria, there have been two failed attempts at liberalizing the law. A recent self-administered questionnaire survey conducted among Nigerian physicians has further revealed that only 13% of the doctors were willing to offer abortion services if legally liberalized (57). The majority considered abstinence from premarital sex and contraceptive use as the most effective strategies for reducing abortion-related deaths, whereas a liberalization of the abortion law was not deemed effective. While law change is a prerequisite if women are to be guaranteed access to safe abortion services, that in itself is not enough. Columbia, Ethiopia and Cambodia are examples of countries where although legal reform took place some years ago, social norms regarding abortion are only beginning to change and consequently many unsafe abortions are still taking place. In Columbia, the high court partly depenalized abortion in 2006; however, government gures from 2009 show that less than 3 000 legal abortions were performed, while between 320 000 and 450 000 backstreet abortions are estimated to take place every year (58). A Columbian survey from 2007 has further revealed that while 85% of gynecologists favored the new abortion law, only a third were prepared to perform a legal abortion under any circumstances and only 38% of those said they would be willing to recommend a colleague who does practise abortion (58). In Ethiopia, the law was changed in 2005, but the expansion of safe abortion services has only progressed slowly (59). The slow progress made in implementing the law is reected by an estimated 58 000 Ethiopian women being treated for abortion complications in 2008 (60). In Cambodia, although induced abortion has been legal since 1997, a number of barriers to safe termination services persist and many women still resort to unsafe interventions, as documented in a recent study where 37% of 629 women with abortion complications stated that they had attempted to terminate the pregnancy before presenting for treatment (61). Pervasive stigma against abortion, as well as a lack of knowledge that abortion is legal, keeps women from opting for safe legal abortion (62). The best way to address the problem of unsafe abortion would be to guarantee women easy access to safe legal aborC 2011 The Author Acta Obstetricia et Gynecologica Scandinavica

tion and to ensure that women and healthcare providers are aware of the legal status of abortion. However, in many countries this is not likely to take place in the foreseeable future. Meanwhile, postabortion care programs should be scaled up, as has been demonstrated with success in Bolivia, Mexico (51), Guatemala (50) and Tanzania (63,64). Despite the mentioned efforts in scaling up postabortion care, many women are still often experiencing difculties in accessing treatment for abortion complications. In 2005, about eight million women developed complications from unsafe abortions, but only about ve million received treatment in hospitals and other health facilities, 2.3 million in Asia, 1.7 million in Africa and 1.0 million in Latin America and the Caribbean (65). Hence, there is great space for further advancing womens access to postabortion care. Surgical treatment for incomplete abortion is mainly offered at secondary and tertiary health facilities, and doctors are often the only health professionals permitted to provide treatment for incomplete abortions. As a consequence, the service is often difcult to access for women living in remote rural areas. To provide highly accessible postabortion care at low cost, midlevel providers are increasingly being trained in evacuation procedures. Studies from Kenya and Uganda have documented that nurse-midwives can be successfully trained to carry out postabortion care for complications of incomplete abortion using MVA (66) However, in Ghana, where nursemidwives are increasingly being trained in the provision of postabortion care, an analysis of provider data from a representative sample of health facilities showed that although the provision of postabortion care by midwives is an efcient and cost-effective strategy for reducing maternal morbidity and mortality, clinical training of midwives leads to a lower yield of postabortion care providers when compared with physicians (67). The study suggested that policy and practice should support postabortion care expansion by trained midwives in the public sector by understanding and eliminating the barriers to provision of services by midwives. Unsafe abortion does not affect everyone equally. Women with nancial means can always nd a way to travel or nd a doctor who will be able to provide a safe legal/illegal abortion, whereas women who live in poverty have a greater risk of resorting to unsafe abortion. To address this problem, more and more efforts have been spent on introducing safe use of medical abortion. Hence, during the past two decades misoprostol has increasingly been used for medical abortion, especially in Latin America, where the drugs availability in pharmacies has greatly improved access to a safe method of abortion. More recently, the drug has also become available in developing countries, such as Cambodia, India, Nepal, South Africa, Tunisia, Vietnam and Zambia. However, while the wider use of misoprostol for medical abortion may help to improve abortion provision in resource-poor countries, it is important to be aware of the feasibility and acceptability

2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 692700

697

Unsafe abortion and postabortion care

V. Rasch

of the method. Hence, if misoprostol is introduced as abortion method at primary care facilities in rural areas, a strong referral system should be in place to treat women who experience a failed attempt to induce the abortion. However, consideration of the possibilities of failed abortion attempts must be seen within the context of the more serious health risks which the women may encounter if they instead have to resort to unsafe abortion methods. Summing up, unsafe abortion remains a major contributor to the high maternal mortality worldwide. The ndings from this overview indicate that achievements have been made during the past years. A number of countries have liberalized their abortion laws, and comprehensive postabortion care programs have been implemented in countries where restrictive abortion laws prevail. However, 40% of the worlds population are still living in countries where abortion is only available to save a womans life or to protect her physical or mental health, and many women who experience abortion complications are still lacking access to comprehensive postabortion care. To reduce the health burden associated with unsafe abortion, there is an ongoing need for reform of abortion laws and a need for improvement of postabortion care coverage. Finally, as most unsafe abortions are consequences of unplanned and unwanted pregnancies, access to highly effective contraceptive methods should be advanced globally.

7.

8.

9.

10.

11. 12.

13.

14.

15.

Funding
No specic funding. References
1. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 19802008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375: 160923. 2. Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, et al. Countdown to 2015 decade report (200010): taking stock of maternal, newborn, and child survival. Lancet. 2010;375:203244. 3. World Health Organization (WHO). Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003, 5th edn. Geneva: WHO, 2007. 4. Singh S, Wulf D, Hussain R, Bankole A, Sedgh G. Abortion worldwide: a decade of uneven progress. New York: Guttmacher Institute, 2009. 5. The worlds abortion laws, fact sheet 2009. Available online at: http://www.crlp.org/pub fac abortion laws.html (accessed October 30, 2010). 6. Jewkes RK, Gumede T, Westaway MS, Dickson K, Brown H, Rees H. Why are women still aborting outside designated 16.

17.

18.

19.

20.

21.

22.

facilities in metropolitan South Africa? BJOG. 2005;112:123642. Singh S, Prada E, Mirembe F, Kiggundu C. The incidence of induced abortion in Uganda. Int Fam Plan Perspect. 2005;31:18391. Juarez F, Singh S, Garcia SG, Olavarrieta CD. Estimates of induced abortion in Mexico: whats changed between 1990 and 2006? Int Fam Plan Perspect. 2008;34:15868. Singh S, Prada E, Kestler E. Induced abortion and unintended pregnancy in Guatemala. Int Fam Plan Perspect. 2006;32:13645. Juarez F, Cabigon J, Singh S, Hussain R. The incidence of induced abortion in the Philippines: current level and recent trends. Int Fam Plan Perspect. 2005;31:1409. Sathar ZA, Singh S, Fikree FF. Estimating the incidence of abortion in Pakistan. Stud Fam Plann. 2007;38:1122. Sedgh G, Henshaw S, Singh S, Ahman E, Shah IH. Induced abortion: estimated rates and trends worldwide. Lancet. 2007;370:133845. Shaikh Z, Abbassi RM, Rizwan N, Abbasi S. Morbidity and mortality due to unsafe abortion in Pakistan. Int J Gynaecol Obstet. 2010;110:479. Rossier C, Guiella G, Ouedraogo A, Thieba B. Estimating clandestine abortion with the condants method results from Ouagadougou, Burkina Faso. Soc Sci Med. 2006;62:25466. Okonofua FE, Shittu SO, Oronsaye F, Ogunsakin D, Ogbomwan S, Zayyan M. Attitudes and practices of private medical providers towards family planning and abortion services in Nigeria. Acta Obstet Gynecol Scand. 2005;84:27080. Rasch V, Kipingili R. Unsafe abortion in urban and rural Tanzania: method, provider and consequences. Trop Med Int Health. 2009;14:112833. Bankole A, Sedgh G, Oye-Adeniran BA, Adewole IF, Hussain R, Singh S. Abortion-seeking behaviour among Nigerian women. J Biosoc Sci. 2008;40:24768. Dahlback E, Maimbolwa M, Yamba CB, Kasonka L, Bergstrom S, Ransjo-Arvidson AB. Pregnancy loss: spontaneous and induced abortions among young women in Lusaka, Zambia. Cult Health Sex. 2010;12:24762. Hill ZE, Tawiah-Agyemang C, Kirkwood B. The context of informal abortions in rural Ghana. J Womens Health (Larchmt). 2009;18:201722. Dahlb ack E, Maimbolwa M, Kasonka L, Bergstr om S, Ransj o-Arvidson AB. Unsafe induced abortions among adolescent girls in Lusaka. Health Care Women Int. 2007;28:65476. World Health Organization (WHO). Safe abortion: technical and policy guidance for health systems. Geneva: WHO, 2003. Kinaro J, Ali TE, Schlangen R, Mack J. Unsafe abortion and abortion care in Khartoum, Sudan. Reprod Health Matters. 2009;17:717.

698

Acta Obstetricia et Gynecologica Scandinavica

C 2011 The Author 2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 692700

V. Rasch

Unsafe abortion and postabortion care

23. Rossier C. Abortion: an open secret? Abortion and social network involvement in Burkina Faso. Reprod Health Matters. 2007;15:2308. 24. Bergsjo P, Vangen S, Lie RT, Lyatuu R, Lie-Nielsen E, Oneko O. Recording of maternal deaths in an East African university hospital. Acta Obstet Gynecol Scand. 2010;89:78993. 25. Nwogu-Ikojo EE, Ezegwui HU. Abortion-related mortality in a tertiary medical centre in Enugu, Nigeria. J Obstet Gynaecol. 2007;27:8357. 26. Kigbu JH, Daru PH, Ujah IA. Review of maternal deaths from unsafe abortion in Jos, Nigeria. Niger J Med. 2009;18:1036. 27. Ziraba AK, Madise N, Mills S, Kyobutungi C, Ezeh A. Maternal mortality in the informal settlements of Nairobi city: what do we know? Reprod Health. 2009;6:6. 28. Baiden F, Mponsa-Achiano K, Oduro AR, Mensah TA, Baiden R, Hodgson A. Unmet need for essential obstetric services in a rural district in northern Ghana: complications of unsafe abortions remain a major cause of mortality. Public Health. 2006;120:4216. 29. Lema VM, Changole J, Kanyighe C, Malunga EV. Maternal mortality at the Queen Elizabeth Central Teaching Hospital, Blantyre, Malawi. East Afr Med J. 2005;82:39. 30. Henshaw SK, Adewole I, Singh S, Bankole A, Oye-Adeniran B, Hussain R. Severity and cost of unsafe abortion complications treated in Nigerian hospitals. Int Fam Plan Perspect. 2008;34:4051. 31. Gebreselassie H, Gallo MF, Monyo A, Johnson BR. The magnitude of abortion complications in Kenya. BJOG. 2005;112:122935. 32. Rasch V, Yambesi F, Kipingili R. Acceptance and use of the female condom among women with incomplete abortion in rural Tanzania. Contraception. 2007;75:6670. 33. Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, et al. Unsafe abortion: the preventable pandemic. Lancet. 2006;368:190819. 34. Curtis C. Meeting health care needs of women experiencing complications of miscarriage and unsafe abortion: USAIDs postabortion care program. J Midwifery Womens Health. 2007;52:36875. 35. Milingos DS, Mathur M, Smith NC, Ashok PW. Manual vacuum aspiration: a safe alternative for the surgical management of early pregnancy loss. BJOG. 2009;116:126871. 36. Wen J, Cai QY, Deng F, Li YP. Manual versus electric vacuum aspiration for rst-trimester abortion: a systematic review. BJOG. 2008;115:513. 37. Billings DL, Benson J. Postabortion care in Latin America: policy and service recommendations from a decade of operations research. Health Policy Plan. 2005;20:15866. 38. Graff M, Amoyaw DA. Barriers to sustainable MVA supply in Ghana: challenges for the low-volume, low-income providers. Afr J Reprod Health. 2009;13:7380.

39. Rasch V, Huber D, Akande EO. Report of the postabortion care technical advisory panel. Washington, DC: United States Agency for International Development [USAID], 2007. 40. Blum J, Winikoff B, Gemzell-Danielsson K, Ho PC, Schiavon R, Weeks A. Treatment of incomplete abortion and miscarriage with misoprostol. Int J Gynaecol Obstet. 2007;99(Suppl 2):S186S189. 41. Dao B, Blum J, Thieba B, Raghavan S, Ouedraego M, Lankoande J, et al. Is misoprostol a safe, effective and acceptable alternative to manual vacuum aspiration for postabortion care? Results from a randomised trial in Burkina Faso, West Africa. BJOG. 2007;114:136875. 42. Bique C, Usta M, Debora B, Chong E, Westheimer E, Winikoff B. Comparison of misoprostol and manual vacuum aspiration for the treatment of incomplete abortion. Int J Gynaecol Obstet. 2007;98:2226. 43. Shwekerela B, Kalumuna R, Kipingili R, Mashaka N, Westheimer E, Clark W, et al. Misoprostol for treatment of incomplete abortion at the regional hospital level: results from Tanzania. BJOG. 2007;114:13637. 44. Weeks A, Alia G, Blum J, Winikoff B, Ekwaru P, Durocher J, et al. A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion. Obstet Gynecol. 2005;106:5407. 45. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 427: Misoprostol for postabortion care. Obstet Gynecol. 2009;113:4658. 46. Gomperts RJ, Jelinska K, Davies S, Gemzell-Danielsson K, Kleiverda G. Using telemedicine for termination of pregnancy with mifepristone and misoprostol in settings where there is no access to safe services. BJOG. 2008;115:11715. 47. Curtis C, Huber D, Moss-Knight T. Postabortion family planning: addressing the cycle of repeat unintended pregnancy and abortion. Int Perspect Sex Reprod Health. 2010;36:448. 48. Ferreira AL, Souza AI, Lima RA, Braga C. Choices on contraceptive methods in post-abortion family planning clinic in the northeast Brazil. Reprod Health. 2010;7:5. 49. McDougall J, Fetters T, Clark KA, Rathavy T. Determinants of contraceptive acceptance among Cambodian abortion patients. Stud Fam Plann. 2009;40:12332. 50. Kestler E, Valencia L, Del Valle V, Silva A. Scaling up post-abortion care in Guatemala: initial successes at national level. Reprod Health Matters. 2006;14:13847. 51. Billings DL, Crane BB, Benson J, Solo J, Fetters T. Scaling-up a public health innovation: a comparative study of post-abortion care in Bolivia and Mexico. Soc Sci Med. 2007;64:221022. 52. Rasch V, Yambesi F, Massawe S. Medium and long-term adherence to postabortion contraception among women having experienced unsafe abortion in Dar es Salaam, Tanzania. BMC Pregnancy Childbirth. 2008;8:32.

C 2011 The Author Acta Obstetricia et Gynecologica Scandinavica

2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 692700

699

Unsafe abortion and postabortion care

V. Rasch

53. Fig` a-Talamanca I, Sinnathuray TA, Yusof K, Fong CK, Palan VT, Adeeb N, et al. Illegal abortion: an attempt to assess its cost to the health services and its incidence in the community. Int J Health Serv. 1986;16:37589. 54. Rasch V, Muhammad H, Urassa E, Bergstrom S. Self-reports of induced abortion: an empathetic setting can improve the quality of data. Am J Public Health. 2000;90:11414. 55. Boland R, Katzive L. Developments in laws on induced abortion: 19982007. Int Fam Plan Perspect. 2008;34:11020. 56. Rahman A, Katzive L, Henshaw SK. A global review of laws on induced abortion, 19851997. Int Fam Plann Persp. 1998;24:5664. 57. Okonta PI, Ebeigbe PN, Sunday-Adeoye I. Liberalization of abortion and reduction of abortion related morbidity and mortality in Nigeria. Acta Obstet Gynecol Scand. 2010;89:108790. 58. Moloney A. Unsafe abortions common in Colombia despite law change. Lancet. 2009;373:534. 59. Singh S, Fetters T, Gebreselassie H, Abdella A, Gebrehiwot Y, Kumbi S, et al. The estimated incidence of induced abortion in Ethiopia, 2008. Int Perspect Sex Reprod Health. 2010;36: 1625. 60. Gebreselassie H, Fetters T, Singh S, Abdella A, Gebrehiwot Y, Tesfaye S, et al. Caring for women with abortion

61.

62.

63.

64.

65.

66.

67.

complications in Ethiopia: national estimates and future implications. Int Perspect Sex Reprod Health. 2010;36:615. Fetters T, Vonthanak S, Picardo C, Rathavy T. Abortion-related complications in Cambodia. BJOG. 2008;115:95768. deRoubaix M. Ten years hence has the South African choice on Termination of Pregnancy Act, Act 92 of 1996, realised its aims? A moral-critical evaluation. Med Law. 2007;26:14577. Rasch V, Yambesi F, Kipingili R. Scaling up postabortion contraceptive service results from a study conducted among women having unwanted pregnancies in urban and rural Tanzania. Contraception. 2005;72:37782. Nielsen KK, Lusiola G, Kanama J, Bantamby J, Kikumbih N, Rasch V. Expanding comprehensive postabortion care to primary health facilities in Geita District, Tanzania. Afr J Reprod Health. 2009;13:12938. Singh S. Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries. Lancet. 2006;368:188792. Berer M. Provision of abortion by mid-level providers: international policy, practice and perspectives. Bull World Health Organ. 2009;87:5863. Clark KA, Mitchell EH, Aboagye PK. Return on investment for essential obstetric care training in Ghana: do trained public sector midwives deliver postabortion care? J Midwifery Womens Health. 2010;55:15361.

700

Acta Obstetricia et Gynecologica Scandinavica

C 2011 The Author 2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 692700