Janie Benson

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.

The clandestine epidemic: the practice of unsafe abortion in Latin America

In Latin America, induced abortion is the fourth most commonly used method of fertility regulation. Estimates of the number of induced abortions performed each year in Latin America range from 2.7 to 7.4 million, or from 10 to 27 percent of all abortions performed in the developing world. Because of restrictive laws, nearly all of these abortions, except for those performed in Barbados, Belize, and Cuba, are clandestine and unsafe, and their sequelae are the principal cause of death among women of reproductive age. One of every three to five unsafe abortions leads to hospitalization, resulting in inordinate consumption of scarce and costly health-system resources. Increased contraceptive prevalence and restrictive abortion laws have not decreased clandestine practices. This article addresses how the epidemic of unsafe abortion might be challenged. Recommendations include providing safer outpatient treatment and strengthening family planning programs to improve womens contraceptive use and their access to information and to safe pregnancy termination procedures. In addition, existing laws and policies governing legal abortion can be applied to their fullest extent, indications for legal abortion can be more broadly interpreted, and legal constraints on abortion practices can be officially relaxed.

Reducing the costs to health systems of unsafe abortion: a comparison of four strategies

Background and methodology Strategies to reduce health systems costs of providing abortion and post-abortion care while simultaneously improving quality of care are well documented but infrequently applied. We created ‘Savings’, a spreadsheet-based tool that allows policymakers and other stakeholders to estimate and compare the feasibility and sustainability of different strategies of providing abortion and post-abortion care. By applying cost data primarily from Uganda, we showed the per-case costs under four policy and service delivery scenarios. Results The mean per-case cost of abortion care (in US dollars) was #45 within the setting that placed heavy restrictions on elective abortion and used a conventional approach to service delivery; #25 within the restrictive legal setting that used recommended interventions for treating complications; #34 within the legal setting that allowed elective abortion and relied on a conventional approach to service delivery; and #6 within the liberal legal setting that used recommended interventions. Discussion and conclusions Using recommended technical interventions substantially reduced costs regardless of the legal setting. The greatest reduction in costs (86%) occurred from using recommended interventions within a liberal legal setting rather than using conventional interventions within a restricted setting. These findings should support policy and practice efforts to reform abortion laws and to offer accessible, safe abortion services.

Counting abortions so that abortion counts: Indicators for monitoring the availability and use of abortion care services

Summary: Maternal mortality reduction has been a focus of major international initiatives for the past two decades. Widespread provision of emergency obstetric care (EmOC) has been shown to be an important strategy for addressing many of the complications that might otherwise lead to maternal death. However, unsafe abortion is one of the major causes of pregnancy‐related deaths, and will be only partially addressed by EmOC. This manuscript presents a comprehensive approach to measuring whether abortion‐related needs are met.

Reductions in abortion-related mortality following policy reform: evidence from Romania South Africa and Bangladesh.

Unsafe abortion is a significant contributor to worldwide maternal mortality; however, abortion law and policy liberalization could lead to drops in unsafe abortion and related deaths. This review provides an analysis of changes in abortion mortality in three countries where significant policy reform and related service delivery occurred. Drawing on peer-reviewed literature, population data and grey literature on programs and policies, this paper demonstrates the policy and program changes that led to declines in abortion-related mortality in Romania, South Africa and Bangladesh. In all three countries, abortion policy liberalization was followed by implementation of safe abortion services and other reproductive health interventions. South Africa and Bangladesh trained mid-level providers to offer safe abortion and menstrual regulation services, respectively, Romania improved contraceptive policies and services, and Bangladesh made advances in emergency obstetric care and family planning. The findings point to the importance of multi-faceted and complementary reproductive health reforms in successful implementation of abortion policy reform.

Meeting the need for safe abortion care in Ethiopia: Results of a national assessment in 2008

Abstract Complications of an unsafe abortion are a major contributor to maternal deaths and morbidity in Africa. When abortions are performed in safe environments, such complications are almost all preventable. This paper reports results from a nationally representative health facility study conducted in Ethiopia in 2008. The safe abortion care (SAC) model, a monitoring approach to assess the amount, distribution, use and quality of abortion services, provided a framework. Data collection included key informant interviews with 335 health care providers, prospective data on 8911 women seeking treatment for abortion complications or induced abortion and review of facility logbooks. Although the existing hospitals perform most basic abortion care functions, the number of facilities providing basic and comprehensive abortion care for the population size fell far short of the recommended levels. Almost one-half (48%) of women treated for obstetric complications in the facilities had abortion complications. The use of appropriate abortion technologies in the first trimester and the provision of post-abortion contraception overall were reasonably strong, especially in private sector facilities. Following abortion law reform in 2005 and subsequent service expansion and improvements, Ethiopia remains committed to reducing complications from an unsafe abortion. This study provides the first national snapshot to measure changes in a dynamic abortion care environment.

Testing the Safe Abortion Care model in Ethiopia to monitor service availability use and quality.

To implement the Safe Abortion Care (SAC) model in public health facilities in the Tigray region of Ethiopia and document the availability, utilization, and quality of SAC services over time.

Early abortion services in the United States: a provider survey

The objective of this study was to describe the availability of early surgical and medical abortion among members of the National Abortion Federation (NAF) and to identify factors affecting the integration of early abortion services into current services. Telephone interviews were conducted with staff at 113 Planned Parenthood affiliates and independent abortion providers between February and April 2000, prior to FDA approval of mifepristone. Early abortion services were available at 59% of sites, and establishing services was less difficult than or about what was anticipated. Sites generally found it easier to begin offering early surgical abortion than early medical abortion. Physician participation was found to be critical to implementing early services. At sites where some but not all providers offered early abortion, variations in service availability resulted. Given the option of reconsidering early services, virtually all sites would make the same decision again. These data suggest that developing mentoring relationships between experienced early abortion providers/sites and those not offering early services, and training physicians and other staff, are likely to be effective approaches to expanding service availability.

Meeting women's needs for post-abortion family planning: Report of a Bellagio Technical Working Group

A Bellagio Technical Working Group meeting sought to develop guidelines for post-abortion family planning services in order to break the cycle of repeated abortions. In the areas of service delivery it was recommended that abortion providers establish links with family planning programs as well as offer some type of contraceptive service whether supplies counseling or referral. To enhance the integration of family planning and abortion services nongovernmental programs are urged to provide menstrual regulation and induced abortion to the fullest limits of local law. In addition there are untapped opportunities for nongovernmental organizations to assist public sector family planning programs through the provision of supplies and training. Community-based distribution workers and pharmacists represent another means of directing women who have received an abortion to contraceptive services. Post-abortion family planning services that are individualized to personal risk factors and needs are more likely to be effective than those based solely on protocols defined by contraceptive method. Similarly program success requires that womens perspectives are incorporated into the design of services. Family planning counselors should develop simple assessment mechanisms to determine the amount level and type of information a woman needs based on her life-style contraceptive history and physical and psychological state. Wherever possible post-abortion family planning care should be delivered in the context of decentralized but comprehensive reproductive health care.

Public hospital costs of treatment of abortion complications in Nigeria

Unsafe abortion is a significant contributor to maternal mortality in Nigeria, and treatment of postabortion complications drains public healthcare resources. Provider estimates of medications, supplies, and staff time spent in 17 public hospitals were used to estimate the per‐case and annual costs of postabortion care (PAC) provision in Ogun and Lagos states and the Federal Capital Territory. PAC with treatment of moderate complications (US