First Trimester Abortion Care in Low and Middle-Income Countries

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First Trimester Abortion Care in Low and Middle-income Countries

ANDREA HENKEL, MD, and KATE A. SHAW, MD, MS Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University, Stanford, California

Abstract: Access to first trimester abortions has account for ~86% of all abortions.1 The increased significantly in the past few decades in low vast majority, nearly 90% of abortions, and middle-income countries. Manual vacuum aspiration is now standard of care for procedural abortion take place in the first trimester. Increased and postabortion care. Medication abortion has access to technology enabling earlier de- shifted abortions to being performed earlier in preg- tection of pregnancy and the rising access nancy and is becoming more widely available with to and use of medication abortion have new service delivery strategies to broaden access. shifted abortions to being performed ear- Widespread availability of misoprostol has made abortions induced outside of the formal medical sector lier in pregnancy. overall safer. In both legally restrictive and supportive In many LMICs, girls are attending environments, there is increased interested in self- school longer, more women are working managed abortions as part of a shift towards deme- outside of the home, and the age at first dicalizing abortion through task-sharing. marriage has increased. Consequently, Key words: abortion, first-trimester, manual vacuum aspirator, misoprostol, mifepristone, self-managed more women desire to delay childbearing and seek greater control over birth-spac- ing. In addition, desired family size has fallen dramatically; the increased desire for Introduction smaller families being most appreciable in Globally, an estimated 56.3 million abor- Asia, Europe, and Central America.2 tions occur each year; those occurring in Rates of unintended and mistimed preg- low-to-middle-income countries (LMICs) nancies have decreased with increasing access to and use of contraception, result- Correspondence: Kate Shaw, MD, MS, Department of ing in a decline in global abortion rates.3 Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University, However, where access to contraception Stanford, CA. E-mail: [email protected] lags behind women’s changing fertility The authors declare that they have nothing to disclose. preferences, women may turn to abortion

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 00 / NUMBER 00 / ’’ 2021

www.clinicalobgyn.com | 1 Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 2 Henkel and Shaw as a way of controlling their fertility. Similarly, after abortion was legalized Therefore, the incidence of abortions may in 2004 in Nepal, the number of women be most reflective of the level of unmet admitted for complications of unsafe need for contraception and contraceptive abortion and the severity of those com- effectiveness in a given geographic area. plications significantly declined; the total number of maternal deaths in Nepal also declined.8 International Abortion Policy Access may depend on what is practi- In the last 20 years, > 30 countries have cally available beyond what is legally amended their laws to expand access to available. The United States remains the safe and legal abortion services.4 How- single largest donor to family planning ever, that still leaves over 40% of women and reproductive health programs over- of reproductive-age living in a country seas.9 However, 2 long standing US pol- where abortion remains highly restricted. icies significantly limit access to abortion: Nearly all countries with the most highly the 1973 Helms amendment, which pro- restrictive laws are LMICs. While there hibits the use of US foreign assistance has been progress in legislatively liberal- funds to pay for the provision of abortion izing abortion access in many LMICs, El services, followed by the 1984 Mexico Salvador and Nicaragua are the notable City Policy, requiring foreign nongovern- exceptions and have taken steps to addi- mental organizations to certify that they tionally restrict abortion. will not perform or promote abortion as a The legislative environment in a coun- method of family planning as a condition try directly impacts the safety of abortion of receiving US funding. Both policies in that country. When legal access to have been rescinded and reinstated by abortion is restricted, women look to alternating administrations along parti- alternatives outside of the formal health san lines and has now been in effect for 19 care sector. Consequently, the prevalence of the past 34 years. of unsafe abortions increases when abor- Many organizations affected by this tion restrictions increase, from 1% of all policy also provide contraception. In an abortions being unsafe in countries with analysis of countries in sub-Saharan Afri- the least-restrictive laws to 31% in those in ca, the use of contraception declined by the most-restrictive laws.5 As restrictive 14% in countries with high-exposure to abortion laws tend to coincide with re- the Mexico City Policy compared with stricting access to modern contraception, those with low-exposure during periods the number of unintended pregnancies when the policy was in place.10 Conse- has increased in LMICs with the most quently, abortion rates increased by 40% restrictive abortion laws.6 As a result, in countries with high-exposure compared abortion rates are paradoxically highest with those countries with low-exposure. in the most legislatively restrictive By reducing these organizations’ ability countries. to supply modern contraceptives, the The impact of liberalizing abortion Mexico City Policy, ironically, increases laws on decreasing maternal mortality abortion rates. has been well characterized in the literature. Six years after liberalizing its abortion laws, South Africa saw a 50% decrease in maternal mortality as rates Unsafe Abortion and of unsafe abortion fell; the number of Postabortion Care (PAC) hospitalizations and severity of postabor- Unsafe abortion remains a top 5 causes of tion complications fell markedly as well.7 maternal mortality with an estimated www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. First Trimester Abortion Care in LMIC 3

47,000 deaths annually attributed to un- globally are unsafe—31% are less safe and safe abortion; nearly all occurring in 14% are least safe.5 Of the estimated 25 LMIC countries.11 A recent systematic million unsafe abortions each year, 97% analysis estimates that 8% of all maternal take place in LMICs. deaths are due to unsafe abortion.12 This Women and untrained providers use finding is lower than the previous assess- many types of traditional and nonmedical ments, either suggesting that maternal methods to end unintended pregnancies. mortality due to unsafe abortion is de- Past reports were rife with women insert- creasing or misclassification and under- ing foreign objects into the vagina or reporting are artificially lowering reports. cervix, liquids into the vagina, consuming There is significant geographic variation alcohol, detergent, bleach, acid, turpen- in proportion of maternal deaths tine, teas or pharmaceuticals, or inducing attributed unsafe abortions: 0.8% in east- trauma to the abdomen. Fortunately, ern Asia, 9.9% in Latin America and the women seeking to terminate a pregnancy Caribbean, and 9.6% in sub-Saharan are increasingly able to obtain misopros- Africa. tol to self-induce an abortion in response The World Health Organization to the WHO’s listing of misoprostol on (WHO) defines unsafe abortion as a the Essential Medication List in 2009.14 procedure for terminating a pregnancy As a result, unsafe abortions are now performed by persons lacking the neces- less unsafe because fewer occur by inva- sary skills or in an environment not in sive or toxic methods. However, women conformity with minimal medical stand- using misoprostol remain at risk of com- ards, or both.13 With recent changes in plications if they cannot get the necessary abortion provision and methods, a broad- information to use the method correctly. er, more nuanced conceptual framework PAC treatment rates have not declined has been proposed to update the WHO despite the increase in access to misopros- definition in 2017.5 According to this tol-only abortions.15 This may reflect a framework, abortions would fall into 1 combination of a relatively high first- of 3 categories: safe, less safe, and least trimester failure rate associated with a safe (with the latter 2 categories together misoprostol-only regimen, many women comprising unsafe abortions). An abor- are inadequately informed about what to tion is classified as safe if it takes place expect and seek care for what is an using a safe method and is done by an otherwise anticipated clinical course of appropriately trained provider (per WHO bleeding or cramping, and some providers guidelines above); less-safe abortions are specifically instruct women to go to facili- those that meet only one of the 2 criteria, ties for surgical aspiration soon after and least-safe abortions are those that bleeding starts.16 meet neither standard (Table 1). Using In 2012, almost 7 million women this definition, about 45% of abortions were treated for complications of unsafe

TABLE 1. World Health Organization Updated Definitions of Abortion Safety (2017)

Traditional Updated Definition Safe Safe Appropriately trained health care provider with methods recommended by World Health Organization Unsafe Less safe Trained providers using nonrecommended (eg, sharp curettage) methods or using a safe method (eg, misoprostol) but without adequate information or support from a trained individual Least safe Untrained people using dangerous, invasive methods

www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 4 Henkel and Shaw abortion in the LMICs.17 The current misoprostol outside of formal health sys- estimated annual PAC treatment rates in tems poses additional challenges for LMICs range from a relative low of 2.4 in measuring abortion incidence in many of Brazil to a high of 14.6 per 1000 women of these countries. A recent study created a reproductive age in Pakistan. In Africa, Bayesian model to estimate the incidence Kenya has the highest rate, with 13.4 per of unintended pregnancy and abortion in 1000 women seeking PAC. Countries 166 developing and developed countries reporting low rates could either represent using country-based surveys and aggre- low levels of morbidity or low levels gated data from studies found through a of access to care. Notably, this study literature search.6 As data surrounding was unable to capture the severity of abortion and unintended pregnancy is complications. Even though the number ubiquitously plagued by underreporting of women treated remains high, the and missing data, their model sought to proportion with severe complications account for the presumed missing data. may have declined with increased access They estimate in 2015 to 2019, there were to misoprostol-only regimens. Thus, 120 million unintended pregnancies annu- the overall unchanged rates of women ally, corresponding to a global rate of 64 seeking out PAC is likely more reflective unintended pregnancies per 1000 women of increased access to PAC which should of reproductive age. This model predicts be viewed as progress in safety. 61% of these unintended pregnancies The WHO’s new guideline Health ended in abortion, for an estimated 73 worker roles in providing safe abortion million abortions annually. care and postabortion contraception high- This same model shows a decreasing lights the importance of enabling a wide trend in unintended pregnancies in the range of health care workers to provide last 30 years. In 1990 to 1994, the global safe abortion and PAC.18 Through annual unintended pregnancy rate was 79 task-sharing in health systems and task- pregnancies per 1000 reproductive-aged specific competency-based training, these women. The estimated decline in unin- guidelines broaden the scope of practice tended pregnancy rate was steepest lead- of many providers in LMICs. For exam- ing into 2000 and has continued to ple, manual vacuum aspiration (MVA) decline. Due to global population growth, can be safely provided by associate (mid- the absolute number of unintended preg- level) clinicians, midwives, nurses, and, in nancies annually continues to increase specific circumstances, other workers even as the relative rate is declining over such as auxiliary nurse midwives. This the analysis period. While the rate of general trend towards reorganizing scopes unintended pregnancies decreased, mod- of practice (often referred to as task- eling predicted that most regions saw an shifting or task-sharing) can improve increase in the percent of unintended access to PAC as this care is time-sensitive pregnancies ending in abortion during and delays in transfers could increase this 30-year analysis period. morbidity. A recent study collated nationally rep- resentative data from 28 LMICs from 4 regions (Africa, Asia, Europe, Latin America and the Caribbean), collected Trends in Those Seeking between 2002 and 2014 offers emerging Abortions in LMICs trends in demographic characteristics of Official statistics are often incomplete or those obtaining abortions by region.19 In poor quality in many LMICs; the in- all 4 regions sampled, most women seek- creased availability of mifepristone and ing abortions were in their 20s. Nigeria www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. First Trimester Abortion Care in LMIC 5 was the one exception where over one countries with education data, women third of abortions took place among with at least 2 year of secondary educa- adolescents. tion accounted for the majority of abor- Among the African countries included tions, similarly ranging from 61% in in this analysis (Congo, Gabon, Ghana, Nigeria to 82% in Gabon. There was wide Nigeria), significant variation existed in the variation in Asian countries consistent distribution of abortions by parity. While with underlying distribution of education- only a quarter of abortions occurred al opportunities by country; the percent- among primiparous women in Congo Re- age of abortions occurring among women public and Gabon, primiparous women in with some secondary education ranged GhanaandNigeriahadthehighest from 22% in Cambodia to 100% in abortion rates. In the Central and South Kyrgyzstan. In Pakistan, Nepal, and America region (Haiti, Mexico), abortions Bangladesh, women with secondary were relatively evenly distributed across education were disproportionately repre- parity, with slightly higher proportions sented among those having abortions. reported among multiparous women. In In a separate analysis from this same 11 of the 12 Asian countries included group, data on the main reason women (Armenia, Azerbaijan, Bangladesh, Cam- give for having an abortion was available bodia, Kyrgyzstan, Pakistan, Tajikistan, for 13 countries.20 More than 1 reason for Turkey, Philippines, Uzbekistan, Vietnam), having an abortion was reported in the the majority of abortions (73% to 85%) majority of cases. Financial concern was occurred among multiparous women. Nep- the most commonly cited reason, fol- al was the outlier in this region where less lowed by wanting to postpone or space a than one third of abortions occurred birth. Other main reasons were partner- among multiparous women. The dispro- related and health-related issues. portionate number of abortions occurring among multiparous married women in Asia suggests that these women may obtain abortions to space births or limit family Procedural Abortion size. The shift towards vacuum aspiration over This study also found that a dispropor- sharp curettage for surgical management tionate proportion of abortions occurred of first trimester abortion was adapted among women of higher socioeconomic globally within the last 2 decades. status in all 4 regions; with notable ex- Vacuum aspiration is associated with ceptions of Armenia and Azerbaijan decreased blood loss, less pain, shorter where a higher proportion of abortions duration of procedure, and fewer compli- occurred among women in the poorest cations than sharp curettage.21 In 2003, wealth quintile. As it is unlikely that the WHO recommended vacuum aspira- women in higher socioeconomic classes tion as the preferred surgical technique have less access to contraception to pre- for first-trimester abortion and strongly vent unintended pregnancy, the dispro- recommends against sharp curettage as a portionate share of abortions among standalone abortion procedure.22 In addi- these women is likely a reflection of better tion, no data suggest that use of curettage access to information on how to obtain following vacuum aspiration decreases abortion services and more empowerment the risk of retained products although to act on fertility preferences. “sharp check,” or 1 pass with a sharp This theory is supported when looking curette at the end of vacuum aspiration, at educational attainment among those remains prevalent as a relic of prior that seek abortions. In 4 of the 5 African practice patterns.

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MVA was designed for use in low- the ongoing shift towards task-sharing to resource settings and is associated with expand abortion access and reduce costs. lower costs compared with electric There is recent evidence that medica- vacuum aspiration (EVA). MVA is more tion abortion can be successfully man- portable, less expensive, and does not aged late in the first trimester, specifically require electricity, making its use favor- for pregnancies through 11 weeks gesta- able in resource-limited settings com- tion. The efficacy of mifepristone and a pared with EVA. A systematic review single dose of misoprostol decreases with comparing MVA with EVA found no advancing gestational age. A systematic difference in complete abortion rates or review reported average efficacy rates of participant satisfaction in early first tri- 96.7% in the eighth week, 95.2% in the mester abortions occurring < 7 weeks ninth week, and 93.1% in the 10th week.27 gestation.23 In addition, MVA was asso- In a noninferiority trial comparing effi- ciated with less blood loss and less pain in cacy of mifepristone and misoprostol in this early first trimester study. among pregnancies 64 to 70 days and 71 In much of the Indian sub-continent, to 77 days of gestation found successful abortion, despite being legal, remains expulsion without surgical intervention highly restricted while menstrual regula- was achieved in 92.3% of the earlier tion (MR) is widely available.24 MR gestational age group and 86.7% of the disrupts an early pregnancy—typically later group.28 The WHO now supports within 14 days of a missed menstrual outpatient medication abortion through period—before it is clinically recognized. 84 days gestation.26 Beyond 12 weeks A small-bore suction is used to “regulate” gestation, repetitive doses of misoprostol the endometrial lining ensuring that a are recommended (Table 2). woman either is not pregnant or does not remain pregnant by disrupting the early embryo. Essentially, this is an early first trimester procedural abortion Impact of Increased Access To without prior pregnancy confirmation. In Medication Abortion 2010, an estimated 653,000 women in Population-level access to misoprostol has Bangladesh obtained MRs, a rate of 18 had a direct impact on safety of abortion. per 1000 women of reproductive age, This was first noted in the 1980s in Brazil similar to abortion rates in surrounding where the incidence of infection was 12 LMIC Asian counties.25 times lower in women using misoprostol compared with women stating that they had used other methods to self-induce Medication Abortion abortion.29 Following government restric- Combination mifepristone and misopros- tions limiting the availability of misoprostol is the preferred medication abortion tol in 1991, 1 Brazilian city experienced a regimen endorsed by the WHO.26 Where tripling of maternal mortality.30 With the mifepristone is unavailable, a misopros- introduction of misoprostol to the Domi- tol-only regimen is acceptable though less nican Republic, abortion complications effective. Given robust evidence showing decreased from 11.7% of abortions in no difference in safety or efficacy by type 1986 to 1.7% in 2001.31 This natural before of trained provider in the first trimester, and after experiment has been repeated in new WHO guidelines recommend that multiple settings and strongly supports medication abortions be provided by access to misoprostol and the inclusion trained mid-level providers instead of of misoprostol on the WHO essential doctors.18 This is overall consistent with medication list. www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. First Trimester Abortion Care in LMIC 7

TABLE 2. Updated Medication Abortion Regimens Per World Health Organization Guidelines (2018)

Combination Regimen (Preferred) Misoprostol-only (Alternative)

Mifepristone 1-2 Days Misoprostol Misoprostol < 12 wk 200 mg PO once 800 µg buccal, PV, 800 µg buccal, PV, or SL once or SL once Over 12 wk 200 mg PO once 400 µg buccal, PV, 400 µg buccal, PV, or SL every 3 h or SL every 3 h

PO indicates oral; PV, vaginal; SL, sublingual.

In a region of some of the most highly when one’s menstrual period is late, this is restrictive abortion laws, the use of miso- an area of growing international interest.34 prostol is now common in much of Latin In the early 1990s, the NGO Women on America and the Caribbean. In 2007, Waves started providing abortions outside misoprostol-only was used in an esti- the territorial waters of countries where mated 30% of abortions in Mexico and abortion was otherwise illegal.35 By ferry- in over 50% of abortions in Colombia.32 ing women into international waters, wom- This trend towards access to and use of en could access abortion care where it was self-managed misoprostol is similar in otherwise highly restricted in their home Africa where nearly 60% of those present- country. Medication abortion was initiated ing for PAC in the second-largest hospital on the boat and PAC including MVA was in Ghana reported using misoprostol.33 available by a gynecologist, if needed. Increased access to misoprostol without a prescription coincided with the worldwide Expanding Access To expansion of the internet. The unmet need for access to abortion care within the Medication Abortion Through formal health sector prompted the develop- Novel Delivery Methods ment of several types of online services that The ease of inducing first trimester abor- facilitate access to self-managed abortion. tion with medication has led to innovative The most established websites are Women service delivery models. on Web (www.womenonweb.org), Aid Ac- Similar to MR described in procedural cess (www.aidaccess.org), safe2choose abortions, there is growing interest and (www.safe2choose.org), and Women Help availability of Missed Period Pills in the Women (www.womenhelp.org). The inter- Indian subcontinent.24 This is provision of net provided an important platform to low-dose mifepristone (100 to 150 mg) and disseminate evidence-based information misoprostol through the medical sector for about timing, dosing schedules, side effects, treatment of delayed menses to allow complications necessitating additional med- women to ensure they are not pregnant ical intervention, and expected outcomes. by inducing bleeding without requiring Frequency of utilization and demand for knowledge of one’s initial pregnancy sta- services on the internet as a means to access tus. This early medication abortion could medication abortion has increased dramat- also be considered a form of postfertiliza- ically in the last 2 decades.36 tion contragestive. As Missed Period Pills Multiple platforms now offer mail decreases logistical challenges of initiating delivery of misoprostol and sometimes contraception before sexual intercourse mifepristone. In a study of the efficacy and may only be needed a few times a year and safety of the Women on Web

www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 8 Henkel and Shaw platform, after online consultation, mife- can be obtained. As such, the current pristone and misoprostol were delivered focus within the Family Planning com- to the homes of 484 women from 33 munity is on addressing these limitations different countries.37 Complications were to make self-managed care even safer and rare and were similar to those undergoing more accessible. a medication abortion supervised by a In many settings, women are required physician: 13.6% reported undergoing a to make a minimum of 2 clinic visits, vacuum aspiration for an incomplete during which they receive pretreatment abortion or for excessive bleeding, 0.8% and posttreatment sonography. The first of women used antibiotics for an infec- ultrasound is to confirm gestational age tion, and 1.6% reported a continuing and candidacy for medication abortion. A pregnancy. recent systematic review suggests that To address the quality of these medi- routine use of ultrasound to determine cations obtained online, a study pur- gestational age before medical abortion chased medications from 18 different may not always be necessary.40 In 4257 websites delivering mifepristone and mi- patients presenting for a medical abortion soprostol to the United States and eval- reporting a last menstrual period uated the drugs they received.38 None of < 70 days, only 4% were in fact greater the websites required a prescription or than 70 days gestation. Of the 2681 who medical consultation. The pills varied in were certain that their last menstrual cost between $110 and $360 USD includ- periods began no > 56 days prior, only ing shipping. Chemical assays determined 0.6% were greater than 70 days gesta- that the tablets labeled mifepristone 200 tional age by ultrasound. This is overall mg were fairly accurate, containing 184.3 reassuring that women can accurately to 204.1 mg of active mifepristone. How- assess their candidacy for medication ever, the tablets labeled misoprostol 200 abortion, particularly in low-resource set- mg were less consistent in quality, con- tings were access to sonography may be taining between 34.1 and 201.4 mg of limited. active misoprostol. Although this model The need for preabortion blood work provides increased access, the variation in to test Rh-status adds an additional touch dosing could lead women to underdose point in the health care system that can be the needed misoprostol for complete burdensome for women or delay care. A abortion. recent flow cytometry study found that fetal red blood cell exposure up to 12 weeks gestation was well below the calculated threshold for maternal Rh sensitiza- The Future of Self-managed tion.41 This conclusion is supported on a Abortion population-level when comparing Cana- The interest in self-managed abortion da and the Netherlands level of clinically extends beyond areas where abortion is significant perinatal antibodies.42 Despite highly restricted and emerging evidence different anti-D IgG treatment policies, suggests this may be the preferred method alloimmunization rates did not differ. The of abortion for many women.39 Nearly all WHO now suggests, but does not require, service delivery models for medical abor- blood group typing when feasible.26 For tion services remains highly medicalized. women obtaining abortions outside of the Many medically unnecessary restrictions traditional health care system using med- exist on where the medications can be ication and not receiving Rh testing, there dispensed and administered, and the tests appears to be little risk of Rh sensitization required before and after the treatment early in the first trimester. www.clinicalobgyn.com Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. First Trimester Abortion Care in LMIC 9

Verifying completion of the abortion delivery strategies to broaden access. often also required an additional touch Despite these advances coinciding with point with the health care system. The the evolving fertility preferences in mod- WHO recommends verifying successful ernizing economies, the legal setting in abortion by pelvic examination, pelvic most LMICs remains restrictive and thus ultrasound, or a repeat human chorionic limiting to further progress. Until contra- gonadotropin measurement.26 There has ception and abortion are widely accessible been recent interest in verifying comple- to women in LMICs, unsafe abortions tion of abortion without another health will remain a prevalent, yet avoidable, care visit. In a meta-analysis of efficacy of cause of maternal mortality. multilevel pregnancy tests (MLPTs) to assess completion of abortion, of the 1482 participants, only 21 (1.3%) had an ongoing pregnancy, none of whom had a References decline in human chorionic gonadotropin bracket on the MLPT.43 MLPT are in- 1. Sedgh G, Bearak J, Singh S, et al. Abortion incidence between 1990 and 2014: global, creasingly available in LMICs and may regional, and subregional levels and trends. become a more wide-spread alternative Lancet. 2016;388:258–267. for verifying completion of abortion, es- 2. Bongaarts J, Mensch BS, Blanc AK. Trends in the pecially for self-managed abortions. age at reproductive transitions in the developing There are large regional differences in world: the role of education. Popul Stud (Camb). 2017;71:139–154. the rates of surgical interventions after 3. Sedgh G, Singh S, Hussain R. Intended and medical abortion provided by telemedi- unintended pregnancies worldwide in 2012 and cine or self-managed abortion.44 High recent trends. Stud Fam Plann. 2014;45:301–314. rates were found in Eastern Europe 4. The Lancet. Abortion: access and safety world- (14.8%), Latin America (14.4%), and wide. Lancet. 2018;391:1121. 5. Ganatra B, Gerdts C, Rossier C, et al. Global, Asia/Oceania (11.0%) and low rates in regional, and subregional classification of Western Europe (5.8%), the Middle East abortions by safety, 2010-14: estimates from a (4.7%), and Africa (6.1%). These differ- Bayesian hierarchical model. Lancet. 2017;390: ences likely reflect different clinical prac- 2372–2381. tice and local guidelines on management 6. Bearak J, Popinchalk A, Ganatra B, et al. Unin- tended pregnancy and abortion by income, re- of incomplete abortion rather than com- gion, and the legal status of abortion: estimates plications that genuinely needed surgical from a comprehensive model for 1990-2019. intervention. As health care providers Lancet Glob Health. 2020;8:e1152–e1161. become increasingly familiar with women 7. Benson J, Andersen K, Samandari G. Reductions self-managing abortions, these rates in abortion-related mortality following policy reform: evidence from Romania, South Africa should standardize. and Bangladesh. Reprod Health. 2011;8:39. 8. Wu WJ, Maru S, Regmi K, et al. Abortion care in Nepal, 15 years after legalization: gaps in access, Conclusions equity, and quality. Health Hum Rights. 2017;19: Access to first trimester abortions has 221–230. 9. Zulu JM, Haaland MES. Situating the increased significantly in the few decades Mexico city policy: what shapes contraceptive in LMICs. MVA is standard of care for access and abortion? Lancet Glob Health. 2019;7: induced procedural abortion and PAC e984–e985. and is widely available in many LMICs, 10. Bendavid E, Avila P, Miller G. United States aid replacing sharp curettage. Medication policy and induced abortion in sub-Saharan Africa. Bull World Health Organ. 2011;89:873. abortion is now more effective with the 11. Ahman E, Shah IH. New estimates and trends addition of mifepristone and is becoming regarding unsafe abortion mortality. Int J Gynae- more widely available with new service col Obstet. 2011;115:121–126.

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