Unsafe Abortion: taking a public health perspective
Islean Kinghorn discusses the public health implications of this emotive issue
WHO defines unsafe abortion as ‘the termination of an unintended pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both.’ (1) According to their statistics 19.7 million women a year undergo unsafe abortions, contributing to 13% of maternal deaths worldwide. (2) If we are to achieve Millennium Development Goal 5 of reducing maternal mortality ratio by ¾ we must address the taboo of unsafe abortion.
The consequences of unsafe abortion on a woman’s health are many. Some such as haemorrhage or infection lead to mortality, while others, including pelvic inflammatory disease, can leave women with chronic pain and an increased risk of obstetric complications or infertility.(3) Such morbidity, easily avoided with safe practice, places a staggering strain on health systems, diverting scant resources from other essential programmes. It has been estimated that each year 5.2 million women are hospitalised worldwide due to complications following unsafe abortion. (4) The global cost to health systems could be as high as US$ 1.08 billion annually. (5) However it is not only the direct but indirect costs, through loss of productivity and the vulnerable position of motherless children, that burden society.
Faced with such risks we must ask ourselves why so many women seek unsafe abortion. It is essential to recognise that the majority of women are not aware of what makes an abortion unsafe or the consequences such a procedure could have on their health. But poverty, child spacing, family planning, relationship problems and pregnancy as a result of rape (3) are all factors driving women to seek termination. These can be seen in all parts of the globe and may explain why the total rate of abortion (abortions per 1000 women aged 15-44) is roughly equal worldwide. (6) Regional disparities for rates of unsafe abortion however are pronounced, with 97% occurring in the developing world. (7)
The Guttmacher Institute New York produces extensive research on all forms of abortion worldwide. Dr Sharon Camp, President and CEO, contends that disparities of unsafe abortion grow out of the status of the law. She believes that for abortion to be accessible for low income women, it needs to be legal and supported by governments and that such legal variance has much to do with the role of women. It has been noted that in areas were women have little involvement in the political system laws tend to be of a more restrictive nature. This has led to the argument that legislation is there to control rather than protect female fertility. If this is not the case why then, when the risk of death from unsafe abortion is 200 times greater than for safe abortion, (10) do countries impose such restrictive laws?
El Salvador and Nicaragua have both tightened restrictions in recent years. (8) “In those countries the current political leadership is very closely tied to the conservative catholic hierarchy and so women’s rights have gone by the board” said Dr Sharon Camp. Michelle Goldberg, an American reporter who has spent many years covering the coming together of politics and ideology, would no doubt agree. She spoke during the Women Deliver conference in London in October about the power of the Vatican and the export of the US evangelist lobbying style to areas of the world including South America. It is important to understand how such cultural backdrops, whether we are sympathetic to them or not, are shaping health policy, and question whether this is right.
Evidence is now mounting that restrictive legislation has little to no effect on abortion rates. Indeed we have seen 17 countries liberalize their abortion laws since 1995 (8) including Portugal where posters could be seen early this year stating, “The abortion problem is not solved by jail, vote Yes.”(6) Romania demonstrates clearly the relationship between criminalization and mortality. Maternal deaths had risen by a factor of five by 1974 (Royston and Armstrong 1989), after restrictive laws were implemented. There was a distinct improvement once these were relaxed at the end of 1989 to produce a 50% reduction in mortality by 1990. (9)
But legality is not the only barrier to safe abortion. Accessibility is crucial in providing safe services, both physical and culturally perceived. In India 90% of abortions still occur outside safe government clinics introduced in 1972. (11) One factor contributing to such a situation is the fact that many women, especially adolescents and unmarried women, are not aware of their legal rights. In many countries this poverty of information is imposed by the USA. The global gag rule officially called the Mexico City Policy “mandates that foreign organisations receiving US governmental assistance for family planning must deny information to women about the option of legal abortion or where safe services can be obtained.” (12) According to Dr Sharon Camp such policies “… have clearly made the situation worse… The gag rule has resulted in a loss of funding for a number of family planning organisations that were the sole source of funding for contraception in their country… I think the shortfalls we are now seeing in contraceptives in developing countries are attributable at least in part to US policy.”
As Dr Camp has pointed out, such legislation not only impacts women’s ability to access safe services, but also increases the possibility of requiring such procedures. NGOs who refuse to adhere to the policy are unable to acquire USAID contraceptives, forcing them to reduce service provisions. Evidence illustrates that increased provision of contraception reduces demand for abortion. (4) (7) (8) The sharpest decline in abortion rates since 1995 has been seen in eastern Europe, where abortions have been available for many years. This change correlates with a sharp increase in the availability of modern contraceptives. (6) In developing countries over 100 million married women have an unmet need for contraception. (8) If we are to reduce the rates of unsafe abortion this demand must be met. It is thought that if contraception were provided to those who are currently unable to access it, maternal mortality could fall by 25-35%. (7)
Abortion has for too long been a subject relegated to the shadows of public health. It is a topic within which many emotional, religious and political perspectives have become entwined, each vying to assert their influence on policy. With so many vested interests what is required is the same detached scrutiny that would be applied to any other public health matter that claimed the lives of 68,000 people a year. (9) The navigation of moral complexities should be left to those directly affected by the outcome- the women themselves.
Islean Kinghorn
3rd year Medical Student
Brighton and Sussex Medical School
islean_x@hotmail.com
(1) Preventing unsafe abortion; The persistent public health problem. www.who.int/reproductive-health/unsafe_abortion/index.html
(2) WHO. 2007. Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003. www.who.int/reproductive-health/publications/unsafeabortion_2003/ua_estimates03.pdf
(3) Grimes D A et al. Unsafe abortion: the preventable pandemic. The Lancet. 2006 Nov 25; 368(9550): 1908-1919
(4) Singh S, Iqbal S H, Standing H. The high cost of unsafe abortion. Id21 health focus. 2007 Aug.
(5) Vlassoff M. The economic impact of unsafe abortion. Id21 health focus. 2007 Aug.
(6) Sedgh G, Henshaw S, Singh S, Ahman E, Shah I H. Induced abortion: estimated rates and trends worldwide. The Lancet. 2007 Oct 13-19; 370(9595): 1338-45
(7) Making abortion legal, safe and rare. The Lancet. 2007 Jul 28; 370(9584): 291
(8) Induced Abortion Worldwide. Guttmacher Institute. 2007 Oct
(9) Gill K, Pande R, Malhotra A. Background Paper for the Women Deliver Conference. 2007 Oct 18-20
(10) Yinger N. Executive Summary for the Women Deliver Conference. 2007 Oct 18-20
(11) Warriner I K, Iqbal S H. Preventing Unsafe Abortion and its Consequences: Priorities for Research and Action [online]. Guttmacher Institute. www.guttmacher.org/pubs/2006/07/10/PreventingUnsafeAbortion.pdf
(12) Fredrick B. Eliminating unsafe abortion worldwide. The Lancet 2007 Oct 13;370(9595):1295-1296.
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