Iqbal H. Shah

Unsafe abortion: the preventable pandemic

Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19-20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalisation of abortion on request is a necessary but insufficient step toward improving womens health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves womens health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.

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.

Fertility Intentions and Reproductive Health Care Needs of People Living with HIV in Cape Town, South Africa: Implications for Integrating Reproductive Health and HIV Care Services

Tailoring sexual and reproductive health services to meet the needs of people living with the human immuno-deficiency virus (HIV) is a growing concern but there are few insights into these issues where HIV is most prevalent. This cross-sectional study investigated the fertility intentions and associated health care needs of 459 women and men, not sampled as intimate partners of each other, living with HIV in Cape Town, South Africa. An almost equal proportion of women (55%) and men (43%) living with HIV, reported not intending to have children as were open to the possibility of having children (45 and 57%, respectively). Overall, greater intentions to have children were associated with being male, having fewer children, living in an informal settlement and use of antiretroviral therapy. There were important gender differences in the determinants of future childbearing intentions, with being on HAART strongly associated with women’s fertility intentions. Gender differences were also apparent in participants’ key reasons for wanting children. A minority of participants had discussed their reproductive intentions and related issues with HIV health care providers. There is an urgent need for intervention models to integrate HIV care with sexual and reproduction health counseling and services that account for the diverse reproductive needs of these populations.

Unsafe Abortion: Global and Regional Incidence, Trends, Consequences, and Challenges

OBJECTIVE This review aims to provide the latest global and regional estimates of the incidence and trends in induced abortion, both safe and unsafe. A related objective is to document maternal mortality due to unsafe abortion. The legal context of abortion and the international discourse on preventing unsafe abortion are reviewed to highlight policy implications and challenges in preventing unsafe abortion. METHODS AND DATA SOURCES: This review is based on estimates of unsafe abortion and maternal mortality ratios. These estimates are arrived at using the database on unsafe abortion maintained by the World Health Organization. Additional data from the Demographic and Health Surveys and the United Nations Population Division are used for further analysis of abortion and mortality estimates. RESULTS Each year 42 million abortions are estimated to take place, 22 million safely and 20 million unsafely. Unsafe abortion accounts for 70,000 maternal deaths each year and causes a further 5 million women to suffer temporary or permanent disability. Maternal mortality ratios (number of maternal deaths per 100,000 live births) due to complications of unsafe abortion are higher in regions with restricted abortion laws than in regions with no or few restrictions on access to safe and legal abortion. CONCLUSION Legal restrictions on safe abortion do not reduce the incidence of abortion. A womans likelihood to have an abortion is about the same whether she lives in a region where abortion is available on request or where it is highly restricted. While legal and safe abortions have declined recently, unsafe abortions show no decline in numbers and rates despite their being entirely preventable. Providing information and services for modern contraception is the primary prevention strategy to eliminate unplanned pregnancy. Providing safe abortion will prevent unsafe abortion. In all cases, women should have access to post-abortion care, including services for family planning. The Millennium Development Goal to improve maternal health is unlikely to be achieved without addressing unsafe abortion and associated mortality and morbidity.

New estimates and trends regarding unsafe abortion mortality

The 1990–2008 estimates for the maternal mortality associated with unsafe abortion require a re‐examination.

Trends in Protective Behaviour among Single vs. Married Young Women in Sub-Saharan Africa: The Big Picture

The trends in contraceptive uptake and condom use among single and married young women show distinct patterns in sub-Saharan Africa. A large median increase of 1.4 percentage points per year in condom use by single young women for pregnancy prevention was witnessed in 18 countries based on Demographic and Health Survey data from 1993 to 2001. In contrast, a modest increase in condom use was noted for married or cohabiting young women. Condom promotion in Africa has been, therefore, a success for single women. Its promotion for pregnancy prevention offers even greater potential, as pregnancy prevention is the main or partial motive of most single women who use condoms. While a myriad of research studies on condom use among young single people have been conducted and published, the needs of the married and cohabiting population have been neglected by researchers and programme staff alike, despite the fact that more than half of HIV infections in the severe epidemics of Southern and East Africa are occurring in this group. The barriers to condom adoption by married couples may not be as severe as is often assumed. Résumé Les tendances dans la prise de contraceptifs et l’utilisation de préservatifs chez les jeunes femmes célibataires et mariées présentent des caractéristiques distinctes en Afrique subsaharienne. De 1993 à 2001, les enquêtes démographiques et sanitaires de 18 pays ont révélé une forte croissance médiane de 1,4 point par année de l’utilisation de préservatifs chez les jeunes femmes célibataires souhaitant éviter une grossesse. Par contre, chez les jeunes femmes mariées ou en cohabitation, cette augmentation a été modeste. La promotion des préservatifs en Afrique a donc été un succès chez les femmes célibataires. Leur promotion pour la prévention des grossesses présente un potentiel encore plus grand, puisque le motif principal ou partiel de la plupart des femmes célibataires utilisant des préservatifs est d’éviter une grossesse. Alors qu’une multitude d’études ont été publiées sur l’emploi des préservatifs chez les jeunes célibataires, les besoins des couples mariés ou qui cohabitent ont été négligés aussi bien par les chercheurs que par le personnel des programmes, alors que plus de la moitié des infections à VIH dans les graves épidémies d’Afrique australe et orientale se produisent dans ce groupe. Les obstacles à l’adoption de préservatifs par les couples mariés ne sont peut-être pas aussi insurmontables qu’on ne le suppose souvent. Resumen Las tendencias en la aceptación de anticonceptivos y en el uso del condón entre las mujeres jóvenes, tanto solteras como casadas, muestran patrones marcados en Africa subsahariana. Con base a los datos de la Encuesta de Demografía y Salud realizada desde 1993 hasta 2001 en 18 países, se presenció un gran aumento promedio del 1.4 por ciento al año en el uso del condón por las mujeres jóvenes para evitar el embarazo. En cambio, entre las casadas o entre las jóvenes en cohabitación, se observó un pequeño aumento. Por tanto, la promoción del condón en Africa ha tenido éxito entre las mujeres solteras. Su promoción para la prevención del embarazo ofrece aun más potencial, dado que éste es el motivo principal o parcial de la mayoría de las mujeres solteras que usan condones. Aunque se han realizado y publicado diversos estudios de investigación sobre el uso del condón entre la gente joven soltera, las necesidades de la población casada y en cohabitación han sido descuidadas tanto por los investigadores como por el personal de programas, pese al hecho de que este grupo presenta más de la mitad de las infecciones por VIH en las graves epidemias de Africa meridional y oriental. Las barreras a la adopción del condón por parte de las parejas casadas posiblemente no sean tan grandes como suele suponerse.

Age patterns of unsafe abortion in developing country regions.

Abstract Globally, 19 million women are estimated to undergo unsafe abortions each year. Age patterns of unsafe abortion are critical for tailoring effective interventions to prevent unsafe abortion and for providing post-abortion care. This paper estimates the incidence and the rate of unsafe abortion among women aged 15—44 in the Africa, Asia (excluding Eastern Asia), and Latin America/Caribbean regions, where a woman is likely to have close to one unsafe abortion by age 44. For developing regions as a whole, two-thirds of unsafe abortions occur among women aged 15—30 and 14% among women under age 20. The age pattern of unsafe abortions differs markedly between regions, however. Almost 60% of unsafe abortions in Africa are among women under age 25 and almost 80% are among women under 30. In Asia 30% of unsafe abortions are in women under 25 and 60% in women under 30. In Latin America and the Caribbean, women aged 20—29 account for more than half of unsafe abortions with almost 70% in women under 30. Over 40% of unsafe abortions among adolescents in the developing world occur in Africa, where one in four unsafe abortions takes place during adolescence. Young (under age 25) women in Africa, those over age 25 in Asia and women aged 20—35 years in Latin America and the Caribbean are in the greatest need of interventions to prevent unsafe abortion and good quality post-abortion care. Résumé On estime que, chaque année, 19 millions de femmes subissent un avortementàrisque dans le monde. Pour intervenir efficacement, il faut connaître la ventilation des avortements par groupes d’âge. L’article évalue l’incidence et le taux d’avortementàrisque chez les femmes de 15à44 ans en Afrique, en Asie (sauf l’Asie de l’Est), en Amérique latine et aux Caraébes, régions où une femme aura subi près d’un avortementàrisque avant 44 ans. Les deux tiers des avortementsàrisque concernent des femmes de 15à30 ans et de 14% des moins de 20 ans. Néanmoins, les âges diffèrent selon les régions. En Afrique, près de 60% des avortementsàrisque se produisent chez des femmes de moins de 25 ans et près de 80% chez les moins de 30 ans. En Amérique latine et aux Caraébes, les femmes âgées de 20à29 ans représentent plus de la moitié des avortementsàrisque, avec près de 70% chez les moins de 30 ans. Plus de 40% des avortementsàrisque chez les adolescentes de pays en développement se produisent en Afrique, où un avortementàrisque sur quatre est pratiqué sur une adolescente. En Afrique, les interventions doivent se centrer sur les femmes de moins de 25 ans, en Asie sur les plus de 25 ans, et en Amérique latine et aux Caraébes, sur les femmes de 20à35 ans. Resumen Se estima que, a nivel mundial,cada año aproximadamente 19 millones de mujeres se someten a abortos. Los patrones de edad del aborto inseguro son fundamentales para adaptar las intervenciones de manera eficaz. En este artáculo se calcula la incidencia y tasa de abortos inseguros en las mujeres de 15 a 44 años de edad en África, Asia (excluida Asia Oriental), Latinoamérica y el Caribe, donde es probable que cada mujer experimente un aborto inseguro antes de cumplir 44 años. Dos terceras partes de los abortos inseguros ocurren entre las mujeres de 15 a 30 años, y el 14% entre las menores de 20 años. No obstante, el patrón de edades de los abortos inseguros difiere marcadamente entre regiones. Casi el 60% de los abortos inseguros en África ocurre entre las mujeres menores de 25 años, y casi el 80% entre aquéllas menores de 30. En Asia, el 30% de abortos inseguros ocurre entre las mujeres menores de 25 y el 60% entre aquéllas menores de 30. En Latinoamérica y el Caribe, casi la mitad de los abortos inseguros se presentan en mujeres de 20 a 29 años; casi el 70% son menores de 30. Más del 40% de los abortos inseguros entre las adolescentes en los paáses en desarrollo ocurren en África donee uno de cuatro abortos inseguros ocurre entre las adolescentes. Para las poláticas y los programas, las intervenciones en África deben centrarse en aquéllas menores de 25; en Asia, en las mayores de 25; y en Latinoamérica y el Caribe, en las de 20 a 35 años.

Provision of DMPA by community health workers: what the evidence shows

BACKGROUND To reduce a large unmet need for family planning in many developing countries, governments are increasingly looking to community health workers (CHWs) as an effective service delivery option for health care and as a feasible option to increase access to family planning services. This article synthesizes evidence on the feasibility, safety and effectiveness of community-based delivery of the injectable contraceptive depot-medroxyprogesterone acetate (DMPA). STUDY DESIGN Manual and electronic search and systematic review of published and unpublished documents on delivery of contraceptive injectables by CHWs. RESULTS Of 600 identified documents, 19 had adequate information on injectables, almost exclusively intramuscular DMPA, provided by CHWs. The data showed that appropriately trained CHW demonstrate competency in screening clients, providing DMPA injections safely and counseling on side effects, although counseling appears equally suboptimal in both clinic and community settings. Clients and CHWs report high rates of satisfaction with community-based provision of DMPA. Provision of DMPA in community-based programs using CHWs expanded access to underserved clients and led to increased uptake of family planning services. CONCLUSIONS We conclude that DMPA can be provided safely by appropriately trained and supervised CHWs. The benefits of community-based provision of DMPA by CHWs outweigh any potential risks, and past experiences support increasing investments in and expansion of these programs.

Unsafe Abortion Differentials in 2008 by Age and Developing Country Region: High Burden Among Young Women

Abstract Each year, nearly 22 million women worldwide have an unsafe abortion, almost all of which occur in developing countries. This paper estimates the incidence and rates of unsafe abortion by five-year age groups among women aged 15–44 years in developing country regions in 2008. Forty-one per cent of unsafe abortions in developing regions are among young women aged 15–24 years, 15% among those aged 15–19 years and 26% among those aged 20–24 years. Among the 3.2 million unsafe abortions in young women 15–19 years old, almost 50% are in the Africa region. 22% of all unsafe abortions in Africa compared to 11% of those in Asia (excluding Eastern Asia) and 16% of those in Latin America and the Caribbean are among adolescents aged 15–19 years. The number of adolescent women globally is approaching 300 million. Adolescents suffer the most from the negative consequences of unsafe abortion. Efforts are urgently needed to provide contraceptive information and services to adolescents, who have a high unmet need for family planning, and to women of all ages, with interventions tailored by age group. Efforts to make abortion safe in developing countries are also urgently needed.