Unsafe Abortion

254 Pages·2006·5.4 MB·English

by  Guttmacher Institute

P P
rio re
rities ven Preventing
Unsafe abortion is a significant yet preventable fo tin
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cause of maternal mortality and morbidity. The R g
gravity and global incidence of unsafe abortion es U
e n
call for a better understanding of the factors behind ar s Unsafe Abortion
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the persistence of unsafe abortion and of the barriers h a fe
to preventing unsafe abortion and managing its conse- nd A
quences. This volume brings together the proceedings Ac bo and its
t r
from an inter-disciplinary consultation to assess the io t
n io
global and regional status of unsafe abortion and to n Consequences

identify a research and action agenda to reduce unsafe a
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abortion and its burden on women, their families, and d

public health systems. The volume addresses a compre- it
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hensive range of issues related to research on prevent- C
Priorities for
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ing unsafe abortion, outlines regional priorities, and
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identifies critical topics for future research and action s
e Research and Action
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on preventing unsafe abortion.
u
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I I
q n Editors
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a K
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H . W Ina K. Warriner
. S a
h rr Iqbal H. Shah
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cover 4.indd 1 31/01/2006 13:34:26
Preventing
Unsafe Abortion
and its
Consequences
Priorities for
Research and Action
Editors
Ina K. Warriner
Iqbal H. Shah
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Suggested citation:
Warriner IK and Shah IH, eds., Preventing Unsafe Abortion and its Consequences: Priorities for
Research and Action, New York: Guttmacher Institute, 2006.
1. Abortion, Induced - adverse effects 2. Abortion, Induced - epidemiology 3. Women’s health
services 4. Health priorities 5. Health policy 6.World health 7. Developing countries I.Warriner,
Ina K. II. Shah, Iqbal H.
ISBN: 0-939253-76-3
Credits
Layout and cover design: Mauro Bernardi
Printed in France
© 2006, Guttmacher Institute, a not-for-profit corporation for sexual and reproductive health
research, policy analysis and public education; all rights, including translation into other lan-
guages, reserved under the Universal Copyright Convention, the Berne Convention for the Pro-
tection of Literary and Artistic Works and the Inter- and Pan-American Copyright Conventions
(Mexico City and Buenos Aires).
Rights to translate information contained in this report may be waived.
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Table of contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
1. Unsafe abortion: an overview of priorities and needs . . . . . . . . . . . . . . . . . 1
Ina K.Warriner
2. Abortion, human rights and the International Conference
on Population and Development (ICPD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Rebecca J.Cook
3. The incidence of unsafe abortion: a global review . . . . . . . . . . . . . . . . . . . . 35
Susheela Singh
4. Determinants of unsafe induced abortion in developing
countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Axel I.Mundigo
5. Reducing the complications of unsafe abortion: the role of
medical technology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
David A.Grimes
6. Meeting women’s health care needs after abortion: lessons
from operations research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Dale Huntington
7. Unsafe abortion in Africa: an overview and recommendations
for action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Charlotte E.Hord, Janie Benson, Jennifer L.Potts & Deborah L.Billings
8. Unsafe abortion in South and South-East Asia: a review of the
evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Bela Ganatra
9. Unsafe abortion in Latin America and the Caribbean:
priorities for research and action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Yolanda Palma, Elsa Lince & Ricardo Raya
iii
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TABLE OF CONTENTS
10. Abortion in Eastern European and Central Asian countries:
priorities for change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Mihai Horga
11. Conclusions and Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Ina K.Warriner & Iqbal H.Shah
The Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
iv
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Foreword
This volume speaks to the global burden of unsafe abortion. The cost is largely
borne by those who are most vulnerable and least able to access safe services:
millions of poor women, young women, rural women and their families bear the
lasting consequences of unsafe abortion. It is a cost that gets swept up in the debate
about abortion; a debate that sometimes misses the day-to-day impact unsafe abor-
tion has on women’s lives. This is a story of desperation. This is a story of women’s
use of abortion under the most horrific circumstances. This is a story of the burdens
on medical systems that can barely meet the most basic of needs, much less provide
care for women suffering from entirely preventable injuries.
This book may be read in different ways. For some, the distinction between
unsafe and safe abortions is meaningless because for them abortion is unacceptable
regardless of safety. For others, it will re-dedicate their commitment to improving
the quality of health care for women. It will rekindle their commitment to the provi-
sion of family planning services to reduce unwanted pregnancies and their commit-
ment to replacing unsafe abortion with safe abortion services. But all must confront
the lengths to which women will go and the risks they face when a pregnancy is
unintended. Women bear those costs, their families bear those costs, and ultimately
society bears those costs.
Tales of unsafe abortion lead to several observations, observations that have
been important for me in my own career. Unsafe abortion is widespread; it does
not know national boundaries. Research on abortion and contraception must there-
fore be global. We all have an obligation not only to improve our understanding
of unsafe abortion and its impact on women, but to share it widely. Advances in
research that take place in resource-rich countries must be available to others who
can less well afford to invest in such research. The challenge is global even when
the particular circumstances are very local. That says to me that researchers – and
the agencies that fund researchers – must ensure that their work derives from the
community, involves the community, and can be used by the community.
Another observation is the resolve with which women seek to end unwanted
pregnancies. Unsafe abortion poses a risk across the lifespan. Adolescents facing an
unintended pregnancy before finishing school or finding a stable partner are most
v
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FOREWORD
likely to seek an end to the pregnancy. Adolescents are also at high risk of forced
intercourse, perhaps the worst path to an unwanted pregnancy. These are young
women who are likely to have fewer financial resources and a poor understanding
of an often punitive health care system; hence the risks and potential complications
they face are great. Consequences may include a lifetime of infertility; a condition
that can affect their ability to marry and achieve full adult status in some settings.
But unsafe abortion knows no age boundaries – many an older woman has
believed her reproductive time had passed only to be surprised by a pregnancy!
Contraceptive vigilance may decline along with the perceived risk of pregnancy,
but that is a calculus that is easy to get wrong. The years a woman may be anticipat-
ing as a grandmother may be taken from her – and her family – if she faces death or
infection from an unsafe abortion. The woman, who would be a source of support
for her children and grandchildren, suddenly faces an imperiled future.
The risks of unsafe abortion are not just to the woman involved. Of course, risks
to her health jeopardize her family, but the costs of unsafe abortion are carried by
the whole of the society. How many other lives could be saved if fewer medical
resources were applied to safe abortion rather than to redressing the ravages of
unsafe abortion? What message might we take from this call to prevent unsafe
abortion? I urge the readers of this book to continually remind themselves of the
basic message of unsafe abortion: look at the lengths women will go to end an
unwanted pregnancy. Let our commitment be as great to ensure that women do not
face unwanted pregnancies and that when they do, they do not have to put their
very lives in jeopardy.
Wendy Baldwin
vi
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Preface
Unsafe abortion is a commonly neglected reproductive health care problem
in developing countries, yet it poses a serious threat to the health of millions of
women during their reproductive lives. Until unsafe abortion and its consequences
are eliminated, complications from unsafe abortion will remain a major cause of
maternal mortality and morbidity.
Defined by the World Health Organization (WHO) as the termination of an
unintended pregnancy either by persons lacking the necessary skills or in an envi-
ronment lacking the minimal medical standards, or both, unsafe abortion remains
a frequently unacknowledged public health burden of substantial proportions. The
brunt of unsafe abortions occurs primarily in the developing world. Although most
women seeking abortions are married or in stable unions and already have several
children, an increasing proportion of those seeking abortions are unmarried ado-
lescents, particularly in urban areas. However, throughout the developing world,
countless women are barred from access to safe abortion services due to a combi-
nation of social, economic, religious, and policy factors.
The 1994 International Conference on Population and Development (ICPD)
highlighted the pressing need for work on unsafe abortion, and, in its Programme
of Action, it urged governments and other relevant organizations “to deal with the
health impact of unsafe abortion as a major public health concern and to reduce
the recourse to abortion through expanded and improved family planning services”
(Paragraph 8.25 of the Programme of Action). It further declared: “In circumstanc-
es where abortion is not against the law, such abortion should be safe.” (Paragraph
63i). Although a number of developing countries have liberalized abortion laws,
much work remains to be done to ensure that unsafe abortion becomes a public
health concern of the past.
Relatively few studies have examined unsafe abortion and its consequences in
the wake of ICPD’s call for action. Consequently, there is a clear and pressing need
to define a research agenda and identify advocacy strategies to reduce unsafe abor-
tion. To achieve the overall goal of eliminating unsafe abortion, it is necessary to
understand the factors behind the persistence of unsafe abortion and the opportuni-
ties and barriers to preventing unsafe abortion.
vii
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PREFACE
With this goal in mind, the UNDP/UNFPA/WHO/World Bank Special Pro-
gramme of Research, Development, and Research Training in Human Repro-
duction under the leadership of its Director, Dr Paul F.A. Van Look, convened a
consultation on “Priorities and Needs in the Area of Unsafe Abortion” in Geneva,
Switzerland, in August 2000, to bring together internationally prominent research-
ers from a variety of disciplines to assess the global status of unsafe abortion and
to identify a research and action agenda to reduce unsafe abortion and its burden
on women, their families, and public health systems.
Presentations at the meeting addressed many facets of unsafe abortion, from an
evidence-based global overview to medical advances in treating complications to
regional perspectives and priorities. Participants documented the gravity and glo-
bal reach of unsafe abortion and called for action to reduce unsafe abortion and its
consequences for women and society. Until unsafe abortion is eliminated, women
will continue to suffer the consequences of abortions performed under unsafe con-
ditions. It is hoped that this collection of papers, with their calls for research and
action, will stimulate the international public health community to address unsafe
abortion and reduce the suffering experienced by millions of women who are not
able to access safe abortion services.
This volume is being published by the Guttmacher Institute, the leading
independent think tank on sexual and reproductive health. Guttmacher conducts
research and engages in public education on unsafe abortion, and is currently col-
laborating with WHO and the World Bank to estimate and disseminate information
on the incidence of abortion worldwide. It believes the papers included in this
report advance understanding of the toll of unsafe abortion and provide valuable
insight into the research and action needed to effectively address this problem.
Ina K. Warriner and Iqbal H. Shah
viii
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Acknowledgements
This volume brings together the many contributions of the participants attending
the meeting on "Priorities and Needs in the Area of Unsafe Abortion", organized by
the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Develop-
ment and Research Training in Human Reproduction (HRP) in August 2000. We
are indebted to the participants, including members of HRP's Specialist Panel on
Social Science and Operations Research in Reproductive Health, who brought with
them their commitment to eliminating unsafe abortion, their passion for improving
women’s health, and their expertise and ideas for addressing the problem of unsafe
abortion. It is their dedication to reducing the burden of unsafe abortion on women’s
lives and their calls for action that are reflected in these pages. Thanks are also due
to Dr Wendy Baldwin who so ably chaired the meeting and expertly guided discus-
sions on the many facets and complexities surrounding abortion.
We owe a significant debt of gratitude to the Ford Foundation for generously sup-
porting the publication of this volume through a grant to the Guttmacher Institute.
We would also like to acknowledge the contribution of Mr Mauro Bernardi who
designed the cover and layout of the volume.
Ina K. Warriner and Iqbal H. Shah
ix
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