Safe Abortion: A Public Health Imperative

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March 2000

The international community has recognized that unsafe abortion is a major threat to women's health. By liberalizing restrictive abortion laws and investing in abortion safety, governments can save the lives of tens of thousands of women every year. History has shown that women worldwide, when faced with unwanted pregnancy, seek abortions regardless of the legality of the procedure. Many have no choice but to undergo abortions performed by unqualified practitioners in unhygienic settings. About one-third of the women who have abortions performed under these circumstances experience complications that pose major risks to their lives and health.¹

Complications resulting from an unsafe abortion include:

sepsis, hemorrhage, and uterine perforation - all of which may be fatal if left untreated and often lead to infertility, permanent physical impairment, and chronic morbidity;
gas gangrene and acute renal failure, which contribute to abortion deaths as secondary complications;
chronic pelvic pain, pelvic inflammatory disease, tubal occlusion, secondary infertility, as well as a high risk of ectopic pregnancy, premature delivery, and future spontaneous abortions; and
reproductive tract infections, of which 20-40% lead to pelvic inflammatory disease and consequent infertility.²

Governments should treat unsafe abortion as a major public health concern. They should remove legal barriers to safe abortion services and allocate resources toward improving the quality of abortion care.

Removing Legal Restrictions on Abortion Makes the Procedure Safer

When abortion is legally restricted, women are often forced to obtain unsafe abortions in non-medical facilities, frequently performed by untrained practitioners.

Governments should improve women's access to safe abortion services by removing laws that criminalize the procedure.

Where access to abortion is restricted by law, qualified medical practitioners are usually reluctant to provide the service. In addition, abortion services are rarely available in public hospitals, which are often the only source of safe medical care for low-income women. Services offered in private clinics are likely to be out of reach for these women.³
In countries in which abortion is generally illegal, physicians do not routinely receive training in abortion procedures. As a result, providers may employ outmoded abortion practices.⁴
Fear of criminal prosecution may affect a physician's willingness to treat women with complications arising from spontaneous or unsafe, clandestine abortion. Similarly, women who fear prosecution for having undergone an illegal abortion are more likely to delay seeking care, thereby putting themselves at greater risk.⁵
Legalizing abortion decreases the rate of abortion-related deaths. In the United States, death rates due to abortion decreased 85 % in five years after legalization.⁶ Under Romania's highly restrictive abortion law, the abortion-related death rate reached 100 deaths per 100,000 live births in 1974 and 150 in 1983. In 1989, the government legalized abortion and by the end of 1990, deaths caused by abortion dropped to about 60 per 100,000 live births.⁷ When abortion was made legal in Guyana in 1995, admissions to a capital city hospital for septic and incomplete abortion declined by 41% within six months of enacting the law. Before passage of the law, septic abortion was the third largest cause of admissions to public hospitals and incomplete abortion was the eighth largest.⁸

Governments Should Invest in Safe Abortion Services

The benefits of ensuring access to safe abortion - to women, children, and society - far outweigh the minimal costs.

Governments should invest in making abortion safe and accessible.

Ensuring women's access to safe abortion services may result in lower medical costs for governments. In some low- and middle-income countries, up to 50% of hospital budgets are used to treat complications of unsafe abortion.¹⁴ The treatment of abortion complications uses a disproportionate share of resources, including hospital beds, blood supply, antibiotics, pain control and other medication, operation rooms and services, anesthesia, and medical specialists. Treatment of unsafe abortion complications may require a hospital stay of up to 15 days. In contrast, treatment of spontaneous or uncomplicated abortions usually requires a hospital stay of up to only 3 days.¹⁵
Making abortion more accessible does not increase demand for the procedure. Hence, governments need not fear that the costs of making safe abortion more available will overburden a health care infrastructure.¹⁶ For example, Barbados, Canada, Tunisia, and Turkey all liberalized their laws to increase access to legal abortion, but they did not experience an increase in abortion rates. The Netherlands, with a non-restrictive abortion law, widely accessible contraceptives, and free abortion services, has one of the lowest annual abortion rates in the world.¹⁷
Investing in abortion safety brings long-term benefits for the next generation. Many women who seek abortions already have living children. In a 1990 study of Chile, where all abortion is illegal, 78% of women hospitalized for complications from clandestine abortions were married or in consensual unions and 76% already had children.¹⁸ Young children who lose their mothers to unsafe abortion are likely to have serious health problems of their own. When a mother dies, surviving children tend to receive less health care and education than children with both parents and are much more likely to die than children who live with both parents.¹⁹

According to the World Health Organization, unsafe abortion is "a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both."⁹

At least 78,000 women die each year from complications of unsafe abortion and hundreds of thousands of women suffer from long- or short-term disabilities.¹⁰ In low-income countries, about 200 women die each day as a result of unsafe abortions.¹¹
Unsafe abortion is responsible for 13% of all maternal deaths globally.¹²
Each year, an estimated 20 million unsafe abortions are performed worldwide, 95% of which are performed in low-income countries.¹³

Endnotes

1 Alan Guttmacher Institute Factsheet: Induced Abortion Worldwide (last visited May 12, 2000) , citing Christopher Tietze & Stanley K. Henshaw, Induced Abortion: A World Review 32 (6th ed. 1986).
2 World Health Organization, Unsafe Abortion 3 (1998).
3 Anika Rahman, Laura Katzive & Stanley Henshaw, A Global Review of Laws on Induced Abortion, 1985-1997, 24 International Family Planning Perspectives 56 (1998).
4 Id.
5 Id.
6 Cynthia Indriso & Axel I. Mundigo, Introduction, in Abortion in the Developing World 23,24 (Cynthia Indriso & Axel I. Mundigo eds., 1999) citing Christopher Tietze, Induced abortion: A world review (4th ed. 1981).
7 World Health Organization, supra note 2, at 1 citing E. Royston & S. Armstrong, Preventing maternal deaths (1989).
8 Alan Guttmacher Institute, Sharing Responsibility: Women, Society & Abortion Worldwide at 39 (1999), citing F.E. Nunes & Y.M Delph, Making Abortion Law Reform Work: Steps and Slips in Guyana, 9 Reprod. Health Matters 66-76 (1997).
9 Safe Motherhood Inter-Agency Group (IAG), Facts and Figures: Unsafe Abortion: An Unnecessary Cause of Death (last visited Feb. 17, 2000) .
10 Family Care International, Sexual and Reproductive Health Briefing Cards (1999).
11 Safe Motherhood IAG, Unwanted Pregnancy (last visited Feb. 17, 2000)
citing World Health Organization, Abortion: A Tabulation of Available Information (3rd ed. 1997).
12 Safe Motherhood IAG, Maternal Mortality (last visited Feb. 17, 2000) .
13 Safe Motherhood IAG, Unwanted Pregnancy, supra note 11.
14 World Health Organization, supra note 2, at 4, citing L. Genasci, Brazil to Launch National Programme, 13 People 25 (1986).
15 World Health Organization, supra note 2, at 4, citing I. Figa-Talamanca et al., Illegal Abortion: An Attempt to Assess its Costs to the Health Services and its Incidence in the Community 16 Int'l j. of Health Services 375-389 (1986); J.A. Fortney, The Use of Hospital Resources to Treat Incomplete Abortions: Examples from Latin America 96(6) Pub. health reports 574-579 (1981).
16 Alan Guttmacher Institute, Sharing Responsibility: Women, Society & Abortion Worldwide 46 (1999).
17 Id. at 28, chart 4.5.
18 Alan Guttmacher Institute, Issues in Brief: An Overview of Clandestine Abortion in Latin America (last visited on May 12, 2000) , citing P.A. Lavin, Informe Preliminar Sobre la Caracterización de los Casos y Costo del Tratamiento del Aborto Hospitalizado en Santiago de Chile, Paper Presented at the Research Conference on Induced Abortion in Latin America and the Caribbean, Universidad Externado de Colombia, Bogotá (Nov. 15-18, 1994).
19 Safe Motherhood IAG, Maternal Health: a Vital Social and Economic Investment (last visited Feb. 17, 2000) .