Gilda Sedgh

Induced abortion: incidence and trends worldwide from 1995 to 2008

BACKGROUND Data of abortion incidence and trends are needed to monitor progress toward improvement of maternal health and access to family planning. To date, estimates of safe and unsafe abortion worldwide have only been made for 1995 and 2003. METHODS We used the standard WHO definition of unsafe abortions. Safe abortion estimates were based largely on official statistics and nationally representative surveys. Unsafe abortion estimates were based primarily on information from published studies, hospital records, and surveys of women. We used additional sources and systematic approaches to make corrections and projections as needed where data were misreported, incomplete, or from earlier years. We assessed trends in abortion incidence using rates developed for 1995, 2003, and 2008 with the same methodology. We used linear regression models to explore the association of the legal status of abortion with the abortion rate across subregions of the world in 2008. FINDINGS The global abortion rate was stable between 2003 and 2008, with rates of 29 and 28 abortions per 1000 women aged 15-44 years, respectively, following a period of decline from 35 abortions per 1000 women in 1995. The average annual percent change in the rate was nearly 2·4% between 1995 and 2003 and 0·3% between 2003 and 2008. Worldwide, 49% of abortions were unsafe in 2008, compared to 44% in 1995. About one in five pregnancies ended in abortion in 2008. The abortion rate was lower in subregions where more women live under liberal abortion laws (p<0·05). INTERPRETATION The substantial decline in the abortion rate observed earlier has stalled, and the proportion of all abortions that are unsafe has increased. Restrictive abortion laws are not associated with lower abortion rates. Measures to reduce the incidence of unintended pregnancy and unsafe abortion, including investments in family planning services and safe abortion care, are crucial steps toward achieving the Millennium Development Goals. FUNDING UK Department for International Development, Dutch Ministry of Foreign Affairs, and John D and Catherine T MacArthur Foundation.

Induced abortion: estimated rates and trends worldwide

BACKGROUND Information on incidence of induced abortion is crucial for identifying policy and programmatic needs aimed at reducing unintended pregnancy. Because unsafe abortion is a cause of maternal morbidity and mortality, measures of its incidence are also important for monitoring progress towards Millennium Development Goal 5. We present new worldwide estimates of abortion rates and trends and discuss their implications for policies and programmes to reduce unintended pregnancy and unsafe abortion and to increase access to safe abortion. METHODS The worldwide and regional incidences of safe abortions in 2003 were calculated by use of reports from official national reporting systems, nationally representative surveys, and published studies. Unsafe abortion rates in 2003 were estimated from hospital data, surveys, and other published studies. Demographic techniques were applied to estimate numbers of abortions and to calculate rates and ratios for 2003. UN estimates of female populations and livebirths were the source for denominators for rates and ratios, respectively. Regions are defined according to UN classifications. Trends in abortion rates and incidences between 1995 and 2003 are presented. FINDINGS An estimated 42 million abortions were induced in 2003, compared with 46 million in 1995. The induced abortion rate in 2003 was 29 per 1000 women aged 15-44 years, down from 35 in 1995. Abortion rates were lowest in western Europe (12 per 1000 women). Rates were 17 per 1000 women in northern Europe, 18 per 1000 women in southern Europe, and 21 per 1000 women in northern America (USA and Canada). In 2003, 48% of all abortions worldwide were unsafe, and more than 97% of all unsafe abortions were in developing countries. There were 31 abortions for every 100 livebirths worldwide in 2003, and this ratio was highest in eastern Europe (105 for every 100 livebirths). INTERPRETATION Overall abortion rates are similar in the developing and developed world, but unsafe abortion is concentrated in developing countries. Ensuring that the need for contraception is met and that all abortions are safe will reduce maternal mortality substantially and protect maternal health.

Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends

Periodic estimation of the incidence of global unintended pregnancy can help demonstrate the need for and impact of family planning programs. We draw upon multiple sources of data to estimate pregnancy incidence by intention status and outcome at worldwide, regional, and subregional levels in 2012 and to assess recent trends using previously published estimates for 2008 and 1995. We find that 213 million pregnancies occurred in 2012, up slightly from 211 million in 2008. The global pregnancy rate decreased only slightly from 2008 to 2012, after declining substantially between 1995 and 2008. Eighty-five million pregnancies, representing 40 percent of all pregnancies, were unintended in 2012. Of these, 50 percent ended in abortion, 13 percent ended in miscarriage, and 38 percent resulted in an unplanned birth. The unintended pregnancy rate continued to decline in Africa and in the Latin America and Caribbean region. If the aims of the London Summit on Family Planning are carried out, the incidence of unwanted and mistimed pregnancies should decline in the coming years.

Adolescent pregnancy, birth, and abortion rates across countries: levels and recent trends

Purpose To examine pregnancy rates and outcomes (births and abortions) among 15- to 19-year olds and 10- to 14-year olds in all countries for which recent information could be obtained and to examine trends since the mid-1990s. Methods Information was obtained from countries’ vital statistics reports and the United Nations Statistics Division for most countries in this study. Alternate sources of information were used if needed and available. We present estimates primarily for 2011 and compare them to estimates published for the mid-1990s. Results Among the 21 countries with complete statistics, the pregnancy rate among 15- to 19-year olds was the highest in the United States (57 pregnancies per 1,000 females) and the lowest rate was in Switzerland (8). Rates were higher in some former Soviet countries with incomplete statistics; they were the highest in Mexico and Sub-Saharan African countries with available information. Among countries with reliable evidence, the highest rate among 10- to 14-year olds was in Hungary. The proportion of teen pregnancies that ended in abortion ranged from 17% in Slovakia to 69% in Sweden. The proportion of pregnancies that ended in live births tended to be higher in countries with high teen pregnancy rates (p =.02). The pregnancy rate has declined since the mid-1990s in the majority of the 16 countries where trends could be assessed. Conclusions Despite recent declines, teen pregnancy rates remain high in many countries. Research on the planning status of these pregnancies and on factors that determine how teens resolve their pregnancies could further inform programs and policies.

Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends

BACKGROUND Information about the incidence of induced abortion is needed to motivate and inform efforts to help women avoid unintended pregnancies and to monitor progress toward that end. We estimate subregional, regional, and global levels and trends in abortion incidence for 1990 to 2014, and abortion rates in subgroups of women. We use the results to estimate the proportion of pregnancies that end in abortion and examine whether abortion rates vary in countries grouped by the legal status of abortion. METHODS We requested abortion data from government agencies and compiled data from international sources and nationally representative studies. With data for 1069 country-years, we estimated incidence using a Bayesian hierarchical time series model whereby the overall abortion rate is a function of the modelled rates in subgroups of women of reproductive age defined by their marital status and contraceptive need and use, and the sizes of these subgroups. FINDINGS We estimated that 35 abortions (90% uncertainty interval [UI] 33 to 44) occurred annually per 1000 women aged 15-44 years worldwide in 2010-14, which was 5 points less than 40 (39-48) in 1990-94 (90% UI for decline -11 to 0). Because of population growth, the annual number of abortions worldwide increased by 5.9 million (90% UI -1.3 to 15.4), from 50.4 million in 1990-94 (48.6 to 59.9) to 56.3 million (52.4 to 70.0) in 2010-14. In the developed world, the abortion rate declined 19 points (-26 to -14), from 46 (41 to 59) to 27 (24 to 37). In the developing world, we found a non-significant 2 point decline (90% UI -9 to 4) in the rate from 39 (37 to 47) to 37 (34 to 46). Some 25% (90% UI 23 to 29) of pregnancies ended in abortion in 2010-14. Globally, 73% (90% UI 59 to 82) of abortions were obtained by married women in 2010-14 compared with 27% (18 to 41) obtained by unmarried women. We did not observe an association between the abortion rates for 2010-14 and the grounds under which abortion is legally allowed. INTERPRETATION Abortion rates have declined significantly since 1990 in the developed world but not in the developing world. Ensuring access to sexual and reproductive health care could help millions of women avoid unintended pregnancies and ensure access to safe abortion. FUNDING UK Government, Dutch Ministry of Foreign Affairs, Norwegian Agency for Development Cooperation, The David and Lucile Packard Foundation, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Legal Abortion Worldwide: Incidence and Recent Trends

CONTEXT Information on abortion levels and trends can inform research and policies affecting maternal and reproductive health, but the incidence of legal abortion has not been assessed in nearly a decade. METHODS Statistics on legal abortions in 2003 were compiled for 60 countries in which the procedure is broadly legal, and trends were assessed where possible. Data sources included published and unpublished reports from official national reporting systems, questionnaires sent to government agencies and nationally representative population surveys. The completeness of country estimates was assessed by officials involved in data collection and by in-country and regional experts. RESULTS In recent years, more countries experienced a decline in legal abortion rates than an increase, among those for which statistics are complete and trend data are available. The most dramatic declines were in Eastern Europe and Central Asia, where rates remained among the highest in the world. The highest estimated levels were in Armenia, Azerbaijan and Georgia, where surveys indicate that women will have close to three abortions each on average in their lifetimes. The U.S. abortion rate dropped by 8% between 1996 and 2003, but remained higher than rates in many Northern and Western European countries. Rates increased in the Netherlands and New Zealand. The official abortion rate declined by 21% over seven years in China, which accounted for a third of the worlds legal abortions in 1996. Trends in the abortion rate differed across age-groups in some countries. CONCLUSIONS The abortion rate varies widely across the countries in which legal abortion is generally available and has declined in many countries since the mid-1990s.

Reasons for contraceptive nonuse among women having unmet need for contraception in developing countries.

The level of unmet need for contraception-an important motivator of international family planning programs and policies-has declined only slightly in recent decades. This study draws upon data from 51 surveys conducted between 2006 and 2013 in Africa, Asia, and Latin America and the Caribbean to provide an updated review of the reasons why many married women having unmet need are not practicing contraception. We examine the reasons for contraceptive nonuse and how these reasons vary across countries and according to national levels of unmet need and contraceptive use. We present specific findings regarding the most widespread reasons for nonuse, particularly infrequent sex and concerns regarding side effects or health risks. Our findings suggest that access to services that provide a range of methods from which to choose, and information and counseling to help women select and effectively use an appropriate method, can be critical in helping women having unmet need overcome obstacles to contraceptive use.

Unwanted Pregnancy and Associated Factors Among Nigerian Women

CONTEXT Many Nigerian women experience unwanted pregnancies. To prevent associated health problems, it is important to understand the factors related to unwanted pregnancy in Nigeria. METHODS A community-based survey of 2,978 women aged 15-49 was conducted in eight Nigerian states. Univariate analyses and multivariate logistic regression analyses were used to determine the incidence of unwanted pregnancy, the incidence of seeking an abortion among women with unwanted pregnancies and the factors associated with unwanted pregnancy and abortion-seeking behavior. Additional analyses examined the prevalence of contraceptive use and womens reasons for seeking to terminate unwanted pregnancies and for not practicing contraception at the time their unwanted pregnancies were conceived. RESULTS Twenty-eight percent of respondents reported ever having had an unwanted pregnancy; of those, half reported having attempted to end their last unwanted pregnancy. Forty-three percent of women who sought an abortion did so because they were not married, were too young or were still in school. Of the women who were not practicing contraception when they had the unwanted pregnancy, 44% said that they were unaware of family planning, and 22% that they either did not have access to contraceptive services, services were too expensive or they were afraid of side effects. At the time of the survey, 27% of all respondents were at risk of an unwanted pregnancy. Almost half were unaware of contraceptive methods. CONCLUSIONS Nigerian women often turn to abortion to avoid unwanted births. The provision of family planning counseling and information could substantially reduce the incidence of unwanted pregnancy and induced abortion in Nigeria.

Breastfeeding and maternal HIV-1 disease progression and mortality.

Objective: To examine the association between breastfeeding and disease progression among HIV-infected women in Dar es Salaam, Tanzania. Design and methods: Cohort study design with Cox proportional hazards models. Results: The relative risk of death comparing women who recently had been breastfeeding to those who were not breastfeeding was 0.47 (95% confidence interval, 0.18–1.20). Neither breastfeeding status nor the duration of exclusive or partial breastfeeding was associated with HIV-1 disease progression, represented by death or development of a low CD4 cell count, anemia or excessive weight loss, in multivariate analyses. These associations remained insignificant when women with relatively low and high CD4 cell counts were analyzed separately. Conclusion: There is insufficient evidence to support the hypothesis that breastfeeding is detrimental to the health of HIV-infected women.

The relationship of abortion to trends in contraception and fertility in Brazil Colombia and Mexico.

National and regional estimates of the incidence of induced abortion in Brazil Colombia and Mexico from the late 1970s to the early 1990s indicate a clear rise in the abortion rate in Brazil and increases in the abortion ratio in all three countries. Cross-sectional analysis showed no significant correlation between the abortion rate and contraceptive use except in Mexico in the early 1990s where a strong positive association was observed. Longitudinally the abortion rate increased as contraceptive use increased in most regions of Brazil and Mexico throughout the study period and in parts of Colombia until the mid-1980s. In Colombia and the most urban region of Mexico the abortion rate declined as contraceptive use stabilized or increased. The abortion ratio was positively associated with contraceptive use over time in nearly every region of each country. The role of abortion in fertility decline was greatest in Brazil where the general fertility rate would have been nearly 13% higher in the early 1990s if the abortion ratio had not increased from its level in the late 1970s. Abortion tended to have a greater impact on fertility in regions where contraceptive use was low. Overall contraceptive use appears to have been a more important determinant of fertility than abortion but abortion has played an important subsidiary role in determining fertility levels and trends in these countries. (authors)