Every birth wanted: induced abortion
Induced abortion is one of the most socially and politically sensitive topics in reproductive health, and provokes strong emotional responses from many people. In this article, Dr Jenny Cresswell considers unsafe abortions, their consequences, the scale of the issue, and the growth of medical abortion procedures.
What is induced abortion?
When a woman is faced with an unintended pregnancy she may decide to terminate the pregnancy by inducing an abortion. An induced abortion is the termination of a pregnancy before the fetus is viable: the procedure might be legal or illegal, depending on the law that exists in the country in which she lives and the reason, or ‘grounds’, for wanting a termination; and may be safe or unsafe, depending on a combination of the method(s) used to carry out the abortion, the skill level of the abortion provider, and the environment in which the procedure is done. An additional consideration is gestational age; globally the vast majority (around 90%) of abortions take place during the first trimester of pregnancy.1
There are two main types of methods used by healthcare providers to induce an abortion: surgical methods such as manual vacuum aspiration, and medical methods either using a drug called misoprostol or a combination of mifepristone and misoprostol. The World Health Organization (WHO) publishes regular clinical guidance on best practice for safe abortion based on the available scientific evidence.2
What is an unsafe abortion?
The World Health Organization (WHO) defines an unsafe abortion as:
“A procedure for terminating a pregnancy performed by persons lacking the necessary skills or in an environment not in conformity with minimal medical standards, or both” which is accompanied by the explanatory note: “The persons, skills and medical standards considered safe in the provision of abortion are different for medical and surgical abortion and also depend on the duration of the pregnancy. What is considered ‘safe’ should be interpreted in line with current WHO technical and policy guidance.”3
Under this definition, there is a continuum of risk along a spectrum: not all unsafe procedures are equally risky; for example, the risk of severe complications is much higher in cases where the woman herself or an unqualified practitioner has inserted an object into the uterus to induce the abortion compared to situations where medical abortion pills are taken without a valid prescription. Sometimes women may make more than one attempt, using different methods or providers, to terminate a pregnancy.
What are some of the consequences of an unsafe abortion?
An unsafe abortion may affect a woman’s physical or mental health, and there may be social and/or economic consequences. These consequences vary according to context, but are generally more severe in a country where the legal framework is restrictive or abortion is highly stigmatised.
At the most severe end of the spectrum, it is thought that around 8% of maternal deaths are due to unsafe abortion,4 although scientific data is very difficult to collect due to the frequently clandestine or stigmatised nature of the procedure. Many more women will have some form of morbidity (health complications), ranging from mild to severe. Health complications that may arise from unsafe abortion include haemorrhage and sepsis (infection), and particularly if the initial abortion attempt is incomplete. Nonetheless, some bleeding is normal during a pregnancy termination and would not be considered morbidity.
Women may be socially stigmatised if the community is aware that she has had an abortion. In addition, there may be economic consequences such as the costs of paying fees for the procedure, travel to a health facility or the opportunity costs if a woman is unable to carry out her usual work or attend school.
How big of a problem is unsafe abortion?
It is thought that, globally, there are around 28 abortions per 10000 women aged 15-44 years each year.5 Around half of abortions are probably unsafe.5 There is thought to be an inverse association between the legality of abortion and the abortion rate: fewer abortions are thought to take place in countries that have liberal abortion laws.5
As of 2011, 97% of countries permitted abortion where a termination is required in order to save the mother’s life; (the countries that do not allow abortion for any legal grounds at all are the Dominican Republic, El Salvador, Nicaragua, Chile and Malta); 68% of countries allowed an abortion to preserve the mother’s physical health; and 30% of countries allowed abortion on request.6 Abortion laws are very diverse, and in some countries where abortion is legally permissible it can be very challenging to obtain a procedure to legal challenges or provider refusal.
New developments: the growth of medical abortion
Misoprostol was first developed in the mid-1980s for gastro-intestinal indications, and was added to the WHO Model List of Essential Medicines in 2011 for the prevention of postpartum haemorrhage. It is also reasonably effective at inducing an abortion, particularly when used in combination with mifepristone.
Use of medical abortion is increasing globally. This is an important development because when the medication is taken early in pregnancy health complications arising from the procedure are generally low, and therefore reasonably safe. Furthermore, medical abortion is discreet: women can obtain the tablets from a provider, or even through the internet, and take them at home or somewhere private.
Randomised controlled trials in Nepal7 and Uganda8 have found that appropriately trained mid-level providers can perform medical abortions with equal safety and effectiveness to doctors, an important finding in settings where the doctor to patient ratio is high. Allowing mid-level providers to provide abortions will increase the number of staff and health facilities that are able to offer such services, particularly in primary health care sites, and therefore increase women’s access.
Check the legal status of abortion in your country using the Center for Reproductive Rights’ interactive map (also listed in the See Also section below.) How does the law in your country compare to socially, economically, or geographically similar nations? Do you think the status of law protects or denies women’s reproductive freedom?
© London School of Hygiene & Tropical Medicine