Priorities for Action Research and Abortion Preventing and Unsafe its Consequences nsafe abortion is a significant yet preventable cause of maternal mortality and morbidity. The Ugravity and global incidence of unsafe abortion Preventing call for a better understanding of the factors behind the persistence of unsafe abortion and of the barriers to preventing unsafe abortion and managing its conse- Unsafe Abortion quences. This volume brings together the proceedings from an inter-disciplinary consultation to assess the and its global and regional status of unsafe abortion and to identify a research and action agenda to reduce unsafe abortion and its burden on women, their families, and Consequences public health systems. The volume addresses a compre- hensive range of issues related to research on prevent- ing unsafe abortion, outlines regional priorities, and Priorities for identifies critical topics for future research and action on preventing unsafe abortion. Research and Action Iqbal H. Iqbal Shah H. Warriner Ina K. Editors Ina K. Warriner Iqbal H. Shah cover 4.indd 1 31/01/2006 13:34:26 Preventing Unsafe Abortion and its Consequences Priorities for Research and Action Editors Ina K. Warriner Iqbal H. Shah A-Intro.indd 1 09/02/2006 10:44:45 Suggested citation: Warriner IK and Shah IH, eds., Preventing Unsafe Abortion and its Consequences: Priorities for Research and Action, New York: Guttmacher Institute, 2006. 1. Abortion, Induced - adverse effects 2. Abortion, Induced - epidemiology 3. Women’s health services 4. Health priorities 5. Health policy 6.World health 7. Developing countries I.Warriner, Ina K. II. Shah, Iqbal H. ISBN: 0-939253-76-3 Credits Layout and cover design: Mauro Bernardi Printed in France © 2006, Guttmacher Institute, a not-for-profit corporation for sexual and reproductive health research, policy analysis and public education; all rights, including translation into other lan- guages, reserved under the Universal Copyright Convention, the Berne Convention for the Pro- tection of Literary and Artistic Works and the Inter- and Pan-American Copyright Conventions (Mexico City and Buenos Aires). Rights to translate information contained in this report may be waived. 120 Wall Street New York, NY 10005, USA Telephone: 1-212-248-1111 Fax: 1-212-248-1951 E-mail: [email protected] 1301 Connecticut Avenue NW, Suite 700 Washington, DC 20036, USA www.guttmacher.org A-Intro.indd 2 09/02/2006 10:44:47 Table of contents Foreword . v Preface . vii Acknowledgements . ix 1. Unsafe abortion: an overview of priorities and needs . 1 Ina K.Warriner 2. Abortion, human rights and the International Conference on Population and Development (ICPD) . 15 Rebecca J.Cook 3. The incidence of unsafe abortion: a global review . 35 Susheela Singh 4. Determinants of unsafe induced abortion in developing countries . 51 Axel I.Mundigo 5. Reducing the complications of unsafe abortion: the role of medical technology . 73 David A.Grimes 6. Meeting women’s health care needs after abortion: lessons from operations research . 93 Dale Huntington 7. Unsafe abortion in Africa: an overview and recommendations for action . 115 Charlotte E.Hord, Janie Benson, Jennifer L.Potts & Deborah L.Billings 8. Unsafe abortion in South and South-East Asia: a review of the evidence . 151 Bela Ganatra 9. Unsafe abortion in Latin America and the Caribbean: priorities for research and action . 187 Yolanda Palma, Elsa Lince & Ricardo Raya iii A-Intro.indd 3 09/02/2006 10:44:47 TABLE OF CONTENTS 10. Abortion in Eastern European and Central Asian countries: priorities for change . 209 Mihai Horga 11. Conclusions and Recommendations . 235 Ina K.Warriner & Iqbal H.Shah The Contributors . 241 iv A-Intro.indd 4 09/02/2006 10:44:47 Foreword This volume speaks to the global burden of unsafe abortion. The cost is largely borne by those who are most vulnerable and least able to access safe services: millions of poor women, young women, rural women and their families bear the lasting consequences of unsafe abortion. It is a cost that gets swept up in the debate about abortion; a debate that sometimes misses the day-to-day impact unsafe abor- tion has on women’s lives. This is a story of desperation. This is a story of women’s use of abortion under the most horrific circumstances. This is a story of the burdens on medical systems that can barely meet the most basic of needs, much less provide care for women suffering from entirely preventable injuries. This book may be read in different ways. For some, the distinction between unsafe and safe abortions is meaningless because for them abortion is unacceptable regardless of safety. For others, it will re-dedicate their commitment to improving the quality of health care for women. It will rekindle their commitment to the provi- sion of family planning services to reduce unwanted pregnancies and their commit- ment to replacing unsafe abortion with safe abortion services. But all must confront the lengths to which women will go and the risks they face when a pregnancy is unintended. Women bear those costs, their families bear those costs, and ultimately society bears those costs. Tales of unsafe abortion lead to several observations, observations that have been important for me in my own career. Unsafe abortion is widespread; it does not know national boundaries. Research on abortion and contraception must there- fore be global. We all have an obligation not only to improve our understanding of unsafe abortion and its impact on women, but to share it widely. Advances in research that take place in resource-rich countries must be available to others who can less well afford to invest in such research. The challenge is global even when the particular circumstances are very local. That says to me that researchers – and the agencies that fund researchers – must ensure that their work derives from the community, involves the community, and can be used by the community. Another observation is the resolve with which women seek to end unwanted pregnancies. Unsafe abortion poses a risk across the lifespan. Adolescents facing an unintended pregnancy before finishing school or finding a stable partner are most v A-Intro.indd 5 09/02/2006 10:44:47 FOREWORD likely to seek an end to the pregnancy. Adolescents are also at high risk of forced intercourse, perhaps the worst path to an unwanted pregnancy. These are young women who are likely to have fewer financial resources and a poor understanding of an often punitive health care system; hence the risks and potential complications they face are great. Consequences may include a lifetime of infertility; a condition that can affect their ability to marry and achieve full adult status in some settings. But unsafe abortion knows no age boundaries – many an older woman has believed her reproductive time had passed only to be surprised by a pregnancy! Contraceptive vigilance may decline along with the perceived risk of pregnancy, but that is a calculus that is easy to get wrong. The years a woman may be anticipat- ing as a grandmother may be taken from her – and her family – if she faces death or infection from an unsafe abortion. The woman, who would be a source of support for her children and grandchildren, suddenly faces an imperiled future. The risks of unsafe abortion are not just to the woman involved. Of course, risks to her health jeopardize her family, but the costs of unsafe abortion are carried by the whole of the society. How many other lives could be saved if fewer medical resources were applied to safe abortion rather than to redressing the ravages of unsafe abortion? What message might we take from this call to prevent unsafe abortion? I urge the readers of this book to continually remind themselves of the basic message of unsafe abortion: look at the lengths women will go to end an unwanted pregnancy. Let our commitment be as great to ensure that women do not face unwanted pregnancies and that when they do, they do not have to put their very lives in jeopardy. Wendy Baldwin vi A-Intro.indd 6 09/02/2006 10:44:47 Preface Unsafe abortion is a commonly neglected reproductive health care problem in developing countries, yet it poses a serious threat to the health of millions of women during their reproductive lives. Until unsafe abortion and its consequences are eliminated, complications from unsafe abortion will remain a major cause of maternal mortality and morbidity. Defined by the World Health Organization (WHO) as the termination of an unintended pregnancy either by persons lacking the necessary skills or in an envi- ronment lacking the minimal medical standards, or both, unsafe abortion remains a frequently unacknowledged public health burden of substantial proportions. The brunt of unsafe abortions occurs primarily in the developing world. Although most women seeking abortions are married or in stable unions and already have several children, an increasing proportion of those seeking abortions are unmarried ado- lescents, particularly in urban areas. However, throughout the developing world, countless women are barred from access to safe abortion services due to a combi- nation of social, economic, religious, and policy factors. The 1994 International Conference on Population and Development (ICPD) highlighted the pressing need for work on unsafe abortion, and, in its Programme of Action, it urged governments and other relevant organizations “to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family planning services” (Paragraph 8.25 of the Programme of Action). It further declared: “In circumstanc- es where abortion is not against the law, such abortion should be safe.” (Paragraph 63i). Although a number of developing countries have liberalized abortion laws, much work remains to be done to ensure that unsafe abortion becomes a public health concern of the past.