Memorandum submitted by the Institute
of Development Studies (IDS)
THE CONTRIBUTION
OF UNSAFE
ABORTION TO
MATERNAL MORTALITY
AND MORBIDITY
IN DEVELOPING
COUNTRIES
Context
Unsafe abortion is a particularly serious problem
in many developing countries where abortion laws remain very restricted.
While levels of morbidity and mortality due to unsafe abortion
have fallen dramatically in developed countries, abortion-related
mortality and morbidity are a major public health challenge in
much of the world.[46]
The WHO defines unsafe abortion as 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".[47]
The abortion mortality rate is 0.2-1.2 per 100,000 abortions in
countries where abortion is legal. The mortality rate in countries
where abortion is penalized is 330 per 100,000.[48]
Of the estimated 600,000 women who die each
year from pregnancy-related causes, possibly one in eight is due
to abortion related complications. Out of an estimated 46 million
induced abortions that take place globally every year, around
19 million are considered unsafe in that they take place outside
of the legal framework and are carried out by unregistered practitioners.
About 5.2 million of these women are hospitalised for serious
complications, while an unknown but possibly equal number of women
suffer similarly serious complications but cannot obtain treatment.
As a result, around 70,000 women die each year, making unsafe
abortion the second leading cause of maternal mortality (at around
14% worldwide). This number has remained unchanged since 1990.
In 2000, the rate of unsafe abortion was higher
in Africa and Latin America than in Asia. In Africa, 709 women
die per 100,000 unsafe abortions, compared to 324 in Asia and
100 in Latin America. 5,000 women die each year as a result of
complications from unsafe abortions in Latin America and the Caribbean.—more
than 1/5 of all maternal deaths.[49]
Nearly half of all deaths due to unsafe abortion occur in Africa,
although Africa accounts for only 13% of all women of reproductive
age in developing countries. The most impoverished women are the
ones who have the least access to networks providing safe abortions
in addition to not being able to afford them;[50]
Though more and more unmarried women of adolescent age are getting
abortions, the highest percentage of women seeking abortions are
married women who already have several children.[51]
It is thought that about one-third of women
undergoing unsafe abortions experience serious medical complications,
yet fewer than half of these women receive hospital treatment.
In Latin America, where abortion laws are highly restrictive but
safe services are available in the major urban areas of some countries,
four out of 10 women having abortions are estimated to experience
complications.but only about two-thirds are believed to receive
hospital treatment. In South and Southeast Asia, one-third of
women having abortions are believed to experience complications,
and more than half do not receive hospital treatment. Despite
this, in some countries where abortion is illegal, as many as
two out of every three maternity beds in large urban public hospitals
are taken up by women hospitalized for the treatment of abortion
complications. The problem is exacerbated by inequalities in access
to services within countries. Even where abortion is generally
against the law, better off urban women can often obtain safe
abortions, whereas poor, rural women invariably use unskilled
practitioners. Of these cases, many suffer long-term effects,
including an estimated 1.5 million women who annually suffer secondary
infertility as a result of induced abortion.
Unsafe abortion-related morbidity and mortality
has effects on human welfare and productivity at the level of
individuals, households, communities and the nation and particularly
affects poorer and socially vulnerable populations. It is therefore
a matter of importance for public policy. Some low income countries
(eg Ghana and Nepal) have liberalised their laws in the recent
past. There are indications that in a number of countries with
highly restricted abortion legislation, there is growing openness
to considering the public health arguments for liberalising laws.
Part of the context for this is the Millennium Development Goal
on maternal health. This is a very good moment for pressing home
the public health arguments for liberalising abortion laws, for
improving access to contraception to prevent unwanted pregnancies
and for providing high quality post abortion care services.
There are also very strong economic arguments
for preventing unsafe abortion. A meeting held at the Institute
of Development Studies (UK) on 18-19 April 2007. and funded by
the Hewlett Foundation, brought together experts on unsafe abortion
and economists specialising in costing methods. The meeting reviewed
recent work estimating the cost of unsafe abortion to the health
sector. Two different methods were used to estimate the global
costs to the health sector of unsafe abortions Participants also
discussed the costs to individuals, households and the economy,
and the links between unsafe abortion and poverty. Millions of
women with serious post-abortion complications do not get treatment.
This means that the costs to households and national economies
of lost productivity due to abortion-related injury and death
are considerable. There are also substantial costs in terms of
orphaning of other children.
Key findings on global economic costs were:
— From cost-per-case surveys, the mean
per-patient cost for post-abortion care lies between US$96 and
US$131 (2005 US dollars). The global cost to health systems ranges
from US$509 million to US$676 million.
— Using the "bottom up" costing
method, global health system costs lie between US$677 million
and US$1.08 billion.
— Regionally, Africa and Asia each
have a 42% share of the total global cost, while Latin America
and the Caribbean's share is around 14%.
— Per-patient treatment costs are substantially
higher in southern Africa, eastern Africa and northern Africa.
— These studies offer a conservative
estimate of total costs to already overburdened developing country
health systems. The economic impact of unsafe abortion is several
times larger than estimated health system costs.
It can be concluded that unsafe abortion is
diverting scarce health resources when safe, cost effective alternatives
are available
In recent years, countries such as Nepal, have
responded by liberalising abortion law. When accompanied by expanded
access to safe services, such as in South Africa, this greatly
reduces complications and deaths from unsafe abortion. Another
promising trend is the increased use of new medical technologies
such as mifepristone and misoprostel—the "abortion
pill""—in very early pregnancy. These are an effective
alternative to surgery and further reduce the risk of complications.
Key policy implications that emerged from the
IDS meeting were:
— Health systems in low-income countries
spend large sums treating complications from unsafe abortion despite
the existence of cost-effective alternatives.
— Women need better access to contraceptive
information and services to reduce unintended pregnancies and
abortion (unsafe and safe).
— Where the law broadly permits abortion,
safe services need to be expanded to further reduce women resorting
to unsafe methods.
— Where the law is highly restricted,
access to services for permitted criteria should be effective.
Advocacy should highlight the unacceptable cost of unsafe abortion
and the benefits of expanding the criteria for legal abortion.
— The quality and coverage of post-abortion
care in developing countries need urgent improvement.
46 Guttmacher Institute "Sharing Responsibility:
Women Society and Abortion Worldwide" Michael Vlassoff "Economic
Impact of Abortion Related Morbidity and Mortality: Modeling Worldwide
Estimates"" Unpublished report for the Hewlett Foundation,
30 April 2006 Back
47
RJ Cook, BM Dickens and M Horga (2004). Safe abortion: WHO technical
and policy guidance, International Journal of Gynecology and Obstetrics
86, p 80. Back
48
Warriner IK and Shah IH, eds. (2006). Preventing Unsafe Abortions
and its Consequences Priorities for Action and Research, New York:
Guttmacher Institute, p vii. Back
49
Olukoya, Peju (2004) Reducing Maternal Mortality from Unsafe
Abortion among Adolescents in Africa African Journal of Reproductive
Health, Volume 8, Number 1, 1 April, pp 57-62(6) Back
50
Ibid, p 6. Back
51
WHO (2004). Unsafe abortion, Global and regional estimates of
the incidence of unsafe abortion and associated mortality in 2000,
Geneva: World Health Organization, p 5. Back
|
