Guttmacher Institute,
New York, NY, USA
World Health Organization, Geneva, Switzerland
October 11, 2007, 2007
Induced
abortion: estimated rates and trends worldwide
Summary
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.
Introduction
Induced abortion
is one of the greatest human rights dilemmas of our time. The
need for scientific and objective information on the matter is
therefore imperative. However, because of the sensitive nature
of the topic, data sources are limited and accurate information
on the occurrence of induced abortion is difficult to obtain.
The distinction
between safe and unsafe abortion is crucial because each has different
public-health implications. Safe abortion has few health consequences,
whereas unsafe abortions are a threat to women's health and survival.[1],
[2], [3], [4] and [5] WHO is involved in efforts to improve maternal
health and reduce maternal mortality in 63 priority countries.5
The UN Millennium Development Goals, adopted by 189 nations, include
the goal of improving maternal health and the specific target
of reducing the maternal mortality ratio by three-quarters between
1990 and 2015.6 Unsafe abortion is a major cause of maternal mortality,
and measuring its incidence is important for monitoring progress
on this goal. Unsafe abortion also has other consequences, including
economic costs to health systems and families, stigmatisation,
and psychosocial effects on women.
All abortions,
whether safe or unsafe, are a compelling indicator of the incidence
of unintended pregnancies, and information on abortion rates can
affect the allocation of resources by national authorities, donor
nations, and international agencies for contraceptive services
and supplies.
This Article
presents new estimates of the incidence of induced abortion worldwide,
by region, and according to the safety of the procedure, for 2003,
the most recent year for which worldwide estimates could be made.
We define safe and unsafe abortion and indicate how these definitions
intersect with abortion laws and regulations. This work is the
product of a comprehensive review of the evidence and systematic
methods of estimation, and represents the first known worldwide
assessment of abortion incidence since 1995, when estimates were
originally developed. It used methods similar to those used in
1995, and we assessed trends in safe and unsafe abortion since
that time.
Methods
Data sources
For estimation
purposes, safe abortions were defined as those that meet legal
requirements in countries in which abortion is legally permitted
under a broad range of criteria. Unsafe abortion is defined by
WHO as any procedure to terminate an unintended pregnancy done
either by people lacking the necessary skills or in an environment
that does not conform to minimum medical standards, or both (panel
1).6 These include abortions in countries with restrictive abortion
laws, as well as abortions that do not meet legal requirements
in countries with less restrictive laws. Although there is not
a perfect correlation between the legal status of abortion and
its safety, there is substantial evidence that most abortions
are safe in countries where the procedure is legally permitted
under a broad range of criteria. By contrast, in countries where
the procedure is highly restricted by law, abortions are frequently
done by unqualified providers, are self-induced, or are done by
medical professionals under unhygienic conditions. Even when done
by a trained practitioner, the clandestine and illegal nature
of abortion in these countries usually means that medical back-up
is not immediately available in an emergency, the woman might
not receive appropriate post-abortion care, and if complications
occur the woman might delay seeking care.
Panel 1. Definitions
of safe and unsafe abortion
Safe abortions
Abortions (a)
in countries where abortion law is not restrictive,* and (b) that
meet legal requirements in countries where the law is restrictive.†
Unsafe abortions
Abortions done
either by people lacking the necessary skills or in an environment
that does not conform to minimum medical standards, or both. These
include (a) abortions in countries where the law is restrictive
and (b) abortions that do not meet legal requirements in countries
where the law is not restrictive.
The most current
statistics available on safe abortion for many countries at the
time of data collection were for 2003. Although some statistics
were available for more recent years, having comparable data for
all countries was important in order to produce regional and worldwide
estimates. Estimates of unsafe abortions are based on data and
studies that cover various years, the rough average of which is
2003. Estimates for years other than 2003 were projected forward
or backward to 2003 if data for trends were available. Where there
was no evidence of changes in rates over time, rates from other
years were applied to UN population data for 2003.
Most countries
in which abortion is legally available on request or under a range
of circumstances have a mechanism for collecting statistics on
procedures. We obtained this information from published reports,
websites of or special requests to relevant government agencies,
or databases compiled by WHO Regional Office for Europe or the
Council of Europe.
We examined
reports for information on the completeness of abortion records,
and with every data request we included an inquiry about the completeness
of statistics. Additionally, we consulted available studies and
several national and international experts on the quality of abortion
statistics. These experts included researchers, officials from
government agencies involved in abortion data collection, and
administrators of abortion and family planning programmes who
were familiar with reporting practices. Where statistics were
deemed complete or nearly complete, as was the case in several
northern and western European countries, no adjustments were made.
In other countries, we corrected the reported numbers for under-reporting,
as indicated by experts. We used the same correction factor as
was used in our previous study when we did not have sufficient
evidence of a change in completeness of reporting.1
For two-thirds
of countries for which official reports were available, and in
which abortion is considered safe, the reports were deemed complete
and the data were not adjusted. In the remaining countries, the
average correction factor was 1·4 (which corresponds to
an inflation of the official estimate by 40%). The correction
factors ranged from 1·05 (USA) to 3·0 (Bangladesh).
The inflation factor was high for Bangladesh because official
statistics in that country include only menstrual regulation procedures
(the only legally permissible procedure), most of which are unreported.
In several countries
where abortion is usually legally permissible, accurate abortion
reporting systems are not in place; however, women's reports on
abortion are available from national surveys. In these cases,
we used the number of induced abortions estimated by the surveys.
Because structured surveys, at best, achieve around 80–85%
completeness in reporting on abortion, we increased the survey-based
numbers by 20%, a conservative estimate of the extent of under-reporting
in surveys.7
For a few Asian
and eastern European countries, abortion data were available from
two sources: household surveys for periods close to 2003 and government
statistics for the intervening years between the surveys and 2003.
In countries for which surveys showed more abortions than were
counted in the official statistics, we deemed the survey estimates
to be more complete, since even they are known to undercount abortions.8
We used the trend line from official statistics to project estimates
forward from the survey year to 2003.
For countries
with statistics or survey data for a year within 4 years of 2003
(ie, 1999–2003) and with no information on changes in abortion
levels over time, we applied the rate for the available year to
the population in 2003 to estimate the number of abortions in
2003. For a few countries that lacked sufficient data, either
from official statistics or surveys, we applied a low, medium,
or high-variant abortion rate, on the basis of contraceptive prevalence
and fertility rates.
Two countries
merit special discussion of the methods underlying their estimates,
because of their large populations and the difficulty of estimating
numbers of safe abortions. In India, although official statistics
on legal abortion were known to have omitted many safe abortions
done by physicians, there was little basis for estimating the
incidence of safe abortion in 1995. A 2002 study provided national
abortion estimates based on a survey of facilities in six states.9
The study indicated there were 6·4 million abortions in
India, of which 2·4 million were safe. The total was similar
to our 1995 estimate, but the estimated number of safe abortions
in 2003 was much greater than our 1995 estimate (1·1 million).
In Vietnam, official data show a sharp decline in the number of
abortions since the mid 1990s. However, nationally representative
Demographic and Health Surveys done in 1996 and 2003 indicate
that the abortion rate has been steady or has increased slightly,
and experts indicate that there has been an increase in private
abortions and in those done in public hospitals but not recorded.
These numbers are not captured by official statistics. We applied
the yearly survey-based rate of change to our 1995 estimate, which
was based on government statistics, to obtain an estimate for
2003. More detailed information on data sources used for safe
abortion estimates is available.8
WHO periodically
estimates the incidence of unsafe abortion for each region and
subregion of the world and has done so for the past 20 years.
Unsafe abortion can only be estimated with indirect techniques
that draw on all available evidence, including information on
complications treated in hospitals, studies on conditions of unsafe
abortion, and women's reports in surveys.10 These estimates are
further corroborated with data for fertility rates,11 in relation
to contraceptive prevalence[12] and [13] and trends, and unmet
need for family planning, where available.[14], [15] and [16]
Because there are gaps in the evidence base, there is a degree
of uncertainty and imprecision in country-specific estimates,
which are, therefore, used solely for the purpose of aggregation
to the regional and subregional levels. For countries that have
data for numbers of women hospitalised for abortion complications,
unsafe abortion incidence was estimated by use of an existing
and widely used technique that adjusts these numbers for the estimated
percentage of women having abortions who do not need or do not
receive treatment.17
Reports on household
surveys of women sometimes provide abortion rates, from which
the national number of abortions can be estimated. Some household
surveys report the percentage of women of reproductive age who
have ever had an unsafe abortion, and these percentages were converted
into yearly rates. When data were taken from a subnational hospital
or community-based study, results were weighted to the country's
population to adjust for rural and urban distributions in the
sample compared with the country as a whole. A small number of
countries for which no information was available were assumed
to have the same rate as other countries in the same region, or
as other countries with similar abortion laws and rates of fertility
and contraceptive use. A more detailed description of methods
for estimating unsafe abortion rates is also available.18
Demographic
data
To calculate
the total, safe, and unsafe abortion rates, we used estimates
of the numbers of women of reproductive age (15–44 years)
as the denominator; for calculation of the corresponding ratios,
the denominator was the number of births in 2003.11 To calculate
the proportion of pregnancies that end in abortion, we estimated
the number of pregnancies as the sum of all livebirths, induced
abortions, and spontaneous pregnancy losses (miscarriages and
stillbirths). We estimated the numbers of spontaneous pregnancy
losses using a model-based approach derived from clinical studies
of pregnancy loss by gestational age, which indicated that spontaneous
pregnancy loss is equal to 20% of the number of births plus 10%
of the number of induced abortions.19 Abortion numbers, rates,
and ratios were calculated for regions as defined by the UN (panel
2), which follow familiar geographical divisions.11
Panel 2. UN
listing of countries by geographical region
Africa
Eastern Africa
Burundi, Comoros,
Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mauritius,
Mozambique, Réunion, Rwanda, Somalia, Tanzania, Uganda,
Zambia, Zimbabwe
Middle Africa
Angola, Cameroon,
Central African Republic, Chad, Congo, Democratic Republic of
the Congo, Equatorial Guinea, Gabon, Sao Tome and Principe
Northern Africa
Algeria, Egypt,
Libya, Morocco, Sudan, Tunisia, Western Sahara
Southern Africa
Botswana, Lesotho,
Namibia, South Africa, Swaziland
Western Africa
Benin, Burkina
Faso, Cape Verde, Côte d'Ivoire, Gambia, Ghana, Guinea,
Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal,
Sierra Leone, Togo
Asia
Eastern Asia
China, Hong
Kong Special Administrative Region of China, Macau Special Administrative
Region of China, North Korea, Japan, Mongolia, South Korea
South-central
Asia
Afghanistan,
Bangladesh, Bhutan, India, Iran, Kazakhstan, Kyrgyzstan, Maldives,
Nepal, Pakistan, Sri Lanka, Tajikistan, Turkmenistan, Uzbekistan
Southeastern
Asia
Brunei, Burma,
Cambodia, East Timor, Indonesia, Laos, Malaysia, Philippines,
Singapore, Thailand, Vietnam
Western Asia
Armenia, Azerbaijan,
Bahrain, Cyprus, Georgia, Iraq, Israel, Jordan, Kuwait, Lebanon,
Occupied Palestinian Territory, Oman, Qatar, Saudi Arabia, Syrian
Arab Republic, Turkey, United Arab Emirates, Yemen
Europe
Eastern Europe
Belarus, Bulgaria,
Czech Republic, Hungary, Moldova, Poland, Romania, Russia, Slovakia,
Ukraine
Northern Europe
Channel Islands,
Denmark, Estonia, Finland, Iceland, Ireland, Latvia, Lithuania,
Norway, Sweden, UK
Southern Europe
Albania, Bosnia
and Herzegovina, Croatia, Former Yugoslav Republic of Macedonia,
Greece, Italy, Malta, Portugal, Serbia and Montenegro, Slovenia,
Spain,
Western Europe
Austria, Belgium,
France, Germany, Luxembourg, Netherlands, Switzerland
Latin America
and the Caribbean
Caribbean
Bahamas, Barbados,
Cuba, Dominica, Dominican Republic, Guadeloupe, Haiti, Jamaica,
Martinique, Netherlands Antilles, Puerto Rico, Saint Lucia, Saint
Vincent and the Grenadines, Trinidad and Tobago, United States
Virgin Islands
Central America
Belize, Costa
Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama
South America
Argentina, Bolivia,
Brazil, Chile, Colombia, Ecuador, French Guiana, Guyana, Paraguay,
Peru, Suriname, Uruguay, Venezuela
Northern America
Canada, USA
Oceania
Australia and
New Zealand
Australia, New
Zealand
Melanesia
Fiji, New Caledonia,
Papua New Guinea, Solomon Islands, Vanuatu
Micronesia
Guam, Micronesia
Polynesia
French Polynesia,
Samoa, Tonga
Developed regions
Northern America,
Europe, Japan, Australia, and New Zealand
Developing regions
Africa, Americas,
excluding Canada and USA, Asia excluding Japan, and Oceania excluding
Australia and New Zealand
Role of the
funding source
The funding
source had no role in study design, data collection, data analysis,
data interpretation, or writing of the report. The corresponding
author had full access to all the data in the study and had final
responsibility for the decision to submit for publication.
Results
An estimated
42 million induced abortions occurred in 2003, compared with the
1995 estimate of 46 million (table 1). The abortion rate (yearly
number of induced abortions per 1000 women aged 15–44 years)
worldwide was 29 in 2003, down from 35 in 1995. The total abortion
rate, which can be interpreted as the number of abortions a woman
will have if current rates prevail throughout her reproductive
lifetime, was 1·1 in 1995 and 0·9 in 2003. An assessment
of trends between 1995 and 2003 should take into account the fact
that figures for both years are estimates and are not precise
values. Additionally, improvements in data availability and estimation
methods might have contributed to the higher estimates in Africa
for 2003 than for 1995. However, declines in abortion rates in
some regions are substantial and likely real.
Table 1.
Global and regional
estimated numbers of induced abortion and abortion rates, 2003
and 1995
* Abortions
per 1000 women aged 15–44 years.
The observed
decline was greater in developed regions (panel 2) than in developing
countries. Within the developed regions, the sharpest decline
in abortion rates was in eastern Europe, where it was estimated
to be 90 per 1000 women in 19951 and 44 in 2003. This decline
had already begun before 1995.1 Elsewhere in the developed regions,
the abortion rate declined modestly in Oceania (which consisted
mainly of Australia and New Zealand), and negligibly in northern
America (Canada and the USA).
In the developing
world, the total number of abortions changed very little (from
35·5 million to 35·0 million), but the rate fell
from 34 to 29 per 1000 women (about 15%). In China, which accounts
for a fifth of all abortions worldwide, the rate seemed to have
declined by a little over 20%. When China was excluded, the total
number of abortions in developing countries actually increased
by 1·5 million, and the rate fell by only 9%.
The estimated
absolute number of abortions was greater in 2003 than in 1995
in Africa, but was lower in 2003 in Asia, and Latin America and
the Caribbean. However, the abortion rate seemed to have decreased
in Africa, Asia, and Latin America and the Caribbean. Contrasting
trends in the numbers of abortions and abortion rates were explained
by population growth during this time. Because of the concentration
of the world's population in Asia, more than half of the world's
abortions in 2003 (26·4 million) took place there, and
a substantial proportion of these (8·6 million) were in
China.
Almost half
of all abortions in 2003 were unsafe (table 2). In developed regions,
most abortions (92%) were safe, but in developing countries, more
than half (55%) were unsafe, including 38% of abortions in Asia,
94% in Latin America and the Caribbean, and 98% in Africa. Overall,
97% of all unsafe abortions in 2003 were in developing countries.
Table 2.
Estimated number
of safe and unsafe induced abortions and abortion rates by region
and subregion, 2003
* Abortions
per 1000 women aged 15–44.
† Less than 0·05.
‡ Less than 0·5.
§ WHO published rate of 11 refers to developing regions of
Oceania and does not include populations in Australia and New
Zealand.
The abortion
rate per 1000 women was similar for Africa, Asia, Europe, and
Latin America and the Caribbean, but lower in northern America
and Oceania (table 2). However, there was variation within regions
(the subregional level). In Africa, the abortion rate ranged from
22 (northern Africa) to 39 (eastern Africa), and in Latin America
and the Caribbean, from 25 (Central America) to 35 (Caribbean).
In Asia, the rate ranged from 24 (western Asia) to 39 (southeastern
Asia).
The abortion
rate per 1000 women was lowest in western Europe (12), and was
also quite low in northern and southern Europe (17–18) and
Oceania (17). In these geographic areas, most abortions were legal
and abortion incidence had been low for decades.20 Northern America
also had a low abortion rate of 21. Of the subregions in which
most abortions were legal, two showed continued high rates of
abortion: eastern Europe at 44, and to a lesser extent, eastern
Asia at 28. Although the rate in the eastern European region has
fallen substantially in recent years, it remains higher than in
any other region.
The abortion
ratio (the number of abortions for every 100 livebirths) was about
31 worldwide in 2003 (table 3). Safe and unsafe abortion ratios
were similar to each other (16 and 15, respectively). The abortion
ratios in developing countries tended to be lower than those in
developed countries, even though the rates were comparable or
higher in developing countries, largely because birth rates were
higher in developing countries.
Table 3.
Global, regional,
and subregional estimated abortion ratios and percentages of pregnancies
that ended in abortion, 2003
* Per 100 births.
† Estimated pregnancies including livebirths, induced abortions,
spontaneous abortions, and stillbirths.
‡ Less than 0·5.
§ WHO published ratio of 8 refers to developing regions of
Oceania and does not include births in Australia and New Zealand.
The abortion
ratio was highest in eastern Europe (105 per 100 livebirths) as
a result of both a high incidence of abortion and low fertility
rates. There were slightly more abortions than births on average
in this region. Abortion ratios were also high in eastern Asia
(which is dominated by China), southeastern Asia, and the Caribbean.
There were an
estimated 205 million pregnancies (livebirths, spontaneous miscarriages,
stillbirths, and induced abortions) worldwide in 2003, of which
about 20% ended in induced abortion. In eastern Europe, almost
half of all pregnancies ended in induced abortion, whereas in
northern America, one in five pregnancies ended in abortion. Even
in regions where small proportions of pregnancies end in induced
abortion, such as middle and western Africa, about one in ten
pregnancies were terminated.
Discussion
The findings
presented here provide new estimates of abortion incidence at
the worldwide and regional levels, which had not been updated
since 1995. In the face of a dearth of information for many countries,
particularly those in which abortion laws are highly restrictive,
this study drew on all available sources of information and used
systematic and consistent methods to estimate abortion incidence.
Information on abortion rates and trends has important implications
for stakeholders in many fields, including public health, public
policy, the law, and reproductive rights.
The estimates
presented here indicate that the incidence of induced abortion
worldwide has declined since 1995, but trends have been variable
across regions. The change in developing regions (excluding China)
has been modest. However, a definite and much larger decrease
in the incidence of abortion was seen in the developed regions
as a whole. The most pronounced change was in countries of the
former Soviet Union (principally consisting of eastern Europe,
but also including a few countries in northern Europe, south-central
Asia, and western Asia).[1] and [8] Although the magnitude of
this decline might be overestimated because abortions were increasingly
being done in the private sector and the incidence of such procedures
might be underestimated, the reduction in abortion rates did coincide
with substantial increases in contraceptive use in the region.[21]
and [22] With respect to family planning, the Soviet era was characterised
by restricted access to contraceptive services, combined with
the availability of abortion services at little or no cost to
the woman.23 Since that time, the efforts of international donors
and governmental agencies have resulted in improved access to
contraceptive information and supplies,21 whereas the cost of
abortion has increased in many settings.23
Although abortion
rates and ratios in the countries of the former Soviet Union have
fallen substantially in recent years, the rates in eastern Europe
remain higher than in any other region. This finding suggests
the need for continued improvements in and expansion of contraceptive
service provision. The widespread preference for small families
in this region indicates a high level of need for effective contraception.[21]
and [24]
Abortion incidence
in 2003 was moderate to high in the African region. The estimated
number of unsafe abortions in 2003 was higher than that for 1995,
partly because studies in the intervening period revealed high
levels of unsafe abortion, and partly because the population had
grown. High abortion rates in sub-Saharan Africa coexist with
high levels of unmet need for contraception,25 and the higher
rates in eastern Africa than in western Africa are consistent
with higher overall demand for family planning in eastern Africa.25
Unsafe and safe
abortions correspond in large part with illegal and legal abortions,
respectively (panel 1). The findings presented here indicate that
unrestrictive abortion laws do not predict a high incidence of
abortion, and by the same token, highly restrictive abortion laws
are not associated with low abortion incidence. Indeed, both the
highest and lowest abortion rates were seen in regions where abortion
is almost uniformly legal under a wide range of circumstances.
Results of previous
studies have shown a strong correlation between abortion and contraception
use such that, in settings with steady fertility rates over time,
abortion incidence declines as contraceptive use increases.26
An analysis of trends in eastern Europe and western and south-central
Asia indicates that this pattern is evident in those regions.22
Although abortion
is likely to be safe in countries where it is legally available
under a wide range of circumstances, unsafe abortions still take
place in some of these areas because of poor information or access
to safe medical services. In eastern Europe and central Asia,
8–16 per 100 procedures lead to post-abortion complications
and 15–50% of maternal deaths are related to abortion.21
Some of the high-risk abortions are illegal, whereas others are
legal but done under poor conditions or using inappropriate methods.
More often, however, legal abortions are safe. In the USA, fewer
than 0·3% of women undergoing abortions have a complication
that necessitates admission to hospital,27 and abortions (both
spontaneous and induced) account for 4% of maternal deaths.28
Similarly, some
abortions in restricted settings are done by trained providers,
but most abortions in these settings have high risks to a woman's
life and health. In Africa, where abortion is highly restricted
by law in nearly all countries, there are 650 deaths for every
100 000 procedures, compared with fewer than 10 per 100 000 procedures
in developed regions.18 Worldwide, an estimated 5 million women
are hospitalised every year for treatment of complications related
to unsafe abortion.29 Moreover, illegal procedures are harmful
even when they do not lead to these consequences, because they
require women to take actions in violation of the law and often
without the knowledge or support of their partners or family.
We should also
note that the level of risk associated with unsafe abortion varies
according to circumstances and can change over time. In Peru and
the Philippines the rate of hospitalisation for abortion-related
complications has declined, even as abortion law remained restrictive
and the abortion rate remained constant.[17], [30], [31] and [32]
Access to safer abortion methods (particularly misoprostol-only
abortions) and to better-trained providers has made abortions
safer to some degree in these countries.[30] and [31] Legalisation
of abortion can have a substantial effect on the safety of the
procedure: in South Africa, the incidence of infection from abortion
decreased by 52% after a more liberal abortion law went into effect
in 1997.33
Worldwide, the
rate of unsafe abortion declined slightly between 1995 and 2003,
but the proportion of all abortions that were unsafe increased
from 44% to 48% in the same interval. These findings reinforce
the need to ensure that existing resources for reducing the rates
of unsafe abortions are used as fully as possible. WHO has issued
technical and policy guidance to assist countries in making safe
abortion accessible to the full extent permitted by the law,34
which include: using the safe methods now available for first-trimester
abortions, in particular manual and electric vacuum aspiration
and medical abortion; training providers on safe and aseptic abortion
practice; training mid-level health professionals to do these
procedures to the extent allowed by law; ensuring that the needed
equipment and supplies are available for safe and appropriate
procedures; and providing high quality post-abortion care that
includes contraceptive counselling and services.
At the root
cause of induced abortion is unintended pregnancy. An estimated
108 million married women in developing countries have an unmet
need for contraception,35 and 51 million unintended pregnancies
in developing countries occur every year to women not using a
contraceptive method. Another 25 million happen as a result of
incorrect or inconsistent use of contraception or method failure.36
Meeting the need for contraception and improving the effectiveness
of use among women and couples who are already using contraception
are crucial steps toward reducing the incidence of unintended
pregnancy.
Estimates of
abortion incidence and trends are necessary means of monitoring
and responding to its causes, including unmet need for contraception,
and, in the case of unsafe abortion, consequences such as maternal
morbidity and mortality. In our research, we have been able to
estimate abortion rates and trends by geographic region and according
to the safety of the procedure. Additional research examining
variations within and between regions and over time in the incidence
of unintended pregnancy, the types of abortion procedures used,
and the severity of consequences of unsafe abortion, would help
establish where service improvements are most needed and whether
the health risks associated with unsafe abortion are declining.
In light of the recent mandates of intergovernmental bodies, the
contraceptive and abortion technologies now available, and the
estimates presented here, prevention of unsafe abortion is an
imperative public-health goal.
Contributors
GS participated
in data collection and estimation of safe abortion incidence,
writing portions of the paper, editing the paper, and preparation
of tables. SH, SS, and IHS participated in providing technical
assistance during data collection and analysis, writing portions
of the paper, and editing the paper. EÅ participated in
data collection and estimation of unsafe abortion incidence, writing
portions of the paper, and editing of the paper.
Conflict
of interest statement: We declare that we have no conflict
of interest.
Acknowledgments:
This study was funded by WHO and the World Bank.
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Correspondence
to: Dr Gilda Sedgh, Guttmacher Institute, New York, NY 10038,
USA
* Defined as countries in which abortion is legally permitted
for social or economic reasons or without specification as to
reason, and a few countries and territories with more restrictive
formal laws in which safe abortion is nevertheless broadly available.
† Such abortions are currently too few to be included in
these estimates.
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