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Making abortions safe: a matter of good public health policy and practice.

Abstract

Globally, abortion mortality constitutes at least 130/0 of maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high mortality and morbidity from abortion tend to occur together. Preventing abortion mortality and morbidity in countries where they remain high is a matter of good public health policy, based on good medical practice, and an important part of initiatives to make pregnancy safer. This paper examines the changes in policy and health service provision required to make abortions safe. It is based on a wide-ranging review of published and unpublished sources. In order to be effective, public health measures must take into account the reasons why women have abortions, the kind of abortion services required and at what stages of pregnancy, the types of abortion service providers needed, and training, cost and counselling issues. The transition from unsafe to safe abortions demands: changes at national policy level; abortion training for ser vice providers; the provision of services at the appropriate primary level health service delivery points; and ensuring that women access these services instead of those of untrained providers. Public awareness that abortion services are available is a crucial element of this transition, particularly among adolescent and single women, who tend to have less access to reproductive health services generally. [c] 2000 Bulletin of World Health Organization. Published by Elsevier Science on behalf of Reproductive Health Matters.

Resume

Dans le monde, les deces dus aux avortements representent au moins 13% de la mortalite maternelle. Les procedures non medicalisees, l'absence de formation des praticiens et une legislation restrictive coincident generalement avec des taux eleves de mortalite et de morbidite dues l'avortement. Prevenir cette mortalite et cette morbidite dans les pays ou elles demeurent elevees releve de la politique de sante publique, fondee sur une bonne pratique medicale, et constitue un volet important des initiatives pour diminuer les risques li es a la grossesse. Cet article recense les changements requis dans les politiques et les services de sante pour garantir des avortements surs et s'appuie sur des sources publiees ou non. Pour etre efficaces, les mesures de sante publique doivent tenir compte des raisons qui incitent les femmes avorter, du type de services demandes et quel stade de la grossesse, des types de praticiens necessaires, et des questions de formation, de couts et de conseil. Pour passer d'avottements non medicalises des avortements surs, il faut changer les politiques au niveau national, former les praticiens a l'avortement, proposer des services au niveau approprie des soins de sante primaires et diriger les femmes vers ces services plutot que vers des praticiens non qualifies. La prise de conscience de la disponibilite des services d'avortement est un element crucial de cette transition, particulierement chez les adolescentes et les femmes celibataires, qui ont en general moms acces aux services de sante genesique.

Resumen

La mortalidad a causa de aborto constituye por lo menos el 13 por ciento de la mortalidad materna a nivel global. Donde hayan tasas altas de morbi-mortalidad a causa de aborto suelen coincidir los abortos practicados en condiciones de riesgo por personas no capacitadas con leyes que restringen el acceso al aborto. La prevencion de la morbimortalidad a causa de aborto en paises donde estos factores sean altos es una cuestion de buenas politicas en salud publica fundadas en buenas practicas medicas. Es ademas un elemento importante en las iniciativas disenadas para reducir los riesgos del embarazo. Este articulo examina los cambios en la provision de politicas y servicios de salud que se requieren para eliminar los riesgos asociados con el aborto. Esta basado en una revision amplia de fuentes tanto publicadas como no-editadas. Para ser eficaces, las medidas de salud publica deben tomar en cuenta las razones por las cuales las mujeres recurren al aborto, los tipos de servicios de aborto que ellas requieren, las etapas del embarazo en las cuales los requieren, los tipos de proveedores de servicios de aborto que necesitan, y consideraciones de capacitacion, costos y consejeria. Para efectuar una transicion del abotto en condiciones de riesgo al aborto sin riesgo se exigen cambios en las politicas nacionales, capacitacion para los proveedores de servicios, provision de servicios en los puntos apropiados a nivel primario, y garantias de que las mujeres acudan a estos servicios en lugar de aquellos ofrecidos por proveedores no capacitados. Durante el periodo de transicion, es crucial que el publico tenga conciencia de la disponibilidad de los servicios de aborto, especialmente las mujeres sin pareja estable y las adolescentes, quienes generalmente carecen de un pleno acceso a los servicios de salud reproductiva.

Keywords: unsafe and clandestine abortion; abortion law and policy; abortion providers and services

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THE World Health Organization (WHO) estimates that about 25% of all pregnancies worldwide end in an induced abortion, approximately 50 million each year. Of these, 20 million abortions are being performed under dangerous conditions, either by untrained providers or using unsafe procedures, or both. Deaths as a result of unsafe abortions in developing countries are estimated at 80,000 annually, i.e. 400 deaths per 100,000 abortions. This figure hides substantial regional variation, however, with unsafe abortions in Africa at least 700 times more likely to lead to death than safe abortions in developed countries (Table 1). In the past decade, in spite of improvements in the safety of abortion procedures used and better access to treatment for complications for some women in developing countries, the number of women requiring treatment for serious complications of unsafe abortion remains very high and many women never receive care at all (1-8).

Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high mortality and morbidity from abortion tend to occur in one and the same countries. This paper is about the ways in which good public health policy and good quality medical practice can make abortions safe. It is based on a review of published and unpublished sources found on Medline and Popline, as well as articles in a range of journals, newsletters, books and other publications in the field.

Fertility decline and the need for abortion

Unplanned and unwanted pregnancies constitute a serious public health responsibility. While fertility has declined by almost half in developing countries since the 1960s, (9) the motivation to control and space births has risen faster than contraceptive use. Once people decide they want fewer children, they use a combination of approaches to achieve this, including modern or traditional methods of contraception and abortion. Fertility declines are sometimes attributed only to effective contraceptive practice, but induced abortion is also an important element (10-13). The extent and effectiveness of contraceptive use has an influence on abortion rates, but all contraceptive methods can fail despite correct and consistent use (14,15). In Italy, Turkey and the UK, failure of withdrawal and inconsistent condom and pill use are the most common reasons for abortion (16-18). In Greece and former Yugoslavia, lack of access to modern birth control methods other than safe abortion historically have contributed to high abortion rates (19,20).

The increasing gap between age at menarche and age at marriage means that there is a longer period during which single women may have an unwanted pregnancy. Lack of access to family planning services for young and single women greatly contributes to the rate of abortions. In Argentina, Chile, Ghana, Kenya, and Viet Nam, single women with unwanted pregnancies describe poor communication with partners on sexuality, poor knowledge of fertility and contraception, low contraceptive use rates and/or irregular and ineffective use of contraceptive methods (21-26).

Increased use of condoms, rather than more efficacious contraceptive methods, particularly among those who need dual protection from sexually transmitted diseases and unwanted pregnancy can also result in higher abortion rates (27). Higher abortion rates are often considered a negative outcome of condom use, but rates of sexually transmitted infections, especially HIV, are reduced by the use of condoms. This should be seen as a positive outcome and good public health policy, provided abortion is available and safe.

Most women use contraception - and abortion when necessary - because they want to be good mothers to the children they already have (28). Some are simply not ready or able at a given moment to have children and a small but growing number, whose position deserves respect, do not wish to have children at all (29). Concerns about women's health, family welfare and poverty are common reasons for abortion, especially among women with several children (14,30,31).

In Asian countries, the rate of abortions has been directly influenced by national population policies. In China, after the one-child policy came into effect, there was a great increase in the number of abortions compared to the previous decade (32). Similarly, in Viet Nam, the abortion rate has been influenced by the two-child policy, the desire for smaller families and inadequate contraceptive services (33). In China, Korea and Taiwan, preference for sons also influences abortion decisions in the context of small family norms (34).

Even in countries where contraceptive prevalence is very high, there are still unplanned pregnancies and abortions. The Netherlands (also with a small family norm) has a comprehensive programme of sex education, good contraceptive and emergency contraceptive services and safe, legal abortion services. As few as 60% of first births may be unplanned and the abortion rate is one of the lowest in the world (6 per 1000 in 1994, compared with 26 per 1000 in the USA). Yet abortion remains a necessary part of fertility control (35).

The transition from unsafe to safe abortions

A range of positive steps has been taken to reduce deaths and morbidity from abortion in a growing number of countries in the past 20 years. Since 1980, abortion laws have been liberalised in some form in Albania, Algeria, Barbados, Belgium, Botswana, Bulgaria, Burkina Faso, Cambodia, Canada, the former Czechoslovakia, Ghana, Greece, Guyana, Hungary, Indonesia, Malaysia, Mongolia, Pakistan, Romania, South Africa, Spain, Taiwan and Turkey (36-43). In other countries there have been attempts to liberalise highly restrictive abortion laws and major national debates on abortion (37,44-48). In Brazil, for example, the Congress considered 46 bills on abortion from 1946 to 1995, of which 13 of 16 in the period 1991-95 were favourable towards making abortion legal in some circumstances (49).

Even in the absence of legal change, it has become easier for women to obtain treatment for abortion complications in large hospitals, at least in urban areas. The high cost and poor quality of care available in many developing country public hospitals are also being addressed. Manual vacuum aspiration (MVA) techniques are finally beginning to replace dilatation and curettage (D&C) as the standard of care for incomplete abortion, which in itself reduces complications (15,50,51). Furthermore, there are more abortion providers who have received some training and have greater awareness of safer procedures and practices, so that, for example, in Bangladesh there are fewer serious complications and deaths than there were 10 years ago (7).

In some countries, women themselves are starting to use safer methods for self-induced abortions, in particular intravaginal use of the prostaglandin misoprostol, resulting in fewer complications and shorter hospital stays. This has been well documented in Brazil, (52-56) and is thought to be common elsewhere in the region (57). Such changes have succeeded in reducing at least some of the more appalling examples of morbidity and mortality arising from the insertion of sticks, roots and sharp instruments into the uterus.

Measures carried out on a project basis, however, may not have a public health impact. In Latin America, for example, successful pilot projects to improve the quality of post-abortion care have not always been scaled up or sustained (58). Real progress is dependent on legal and other changes in national policy and practice.

The need to legalise abortion

Making abortion legal is an essential component of making abortion safe. Changing the law does matter and assertions to the contrary are ill-conceived and unsupported in practice. Although in many countries, trends towards safer abortion have often occurred prior to or in the absence of changes in the law, legal changes need to take place if safety is to be sustained for all women.

Safety is not only a question of safe medical procedures being used by individual providers. It is also about removing the risk of exposure and the fear of imprisonment and other punitive measures for both women and providers, even where illegal abortion is tolerated.

Health professionals providing safe but clandestine abortion in urban Latin America have described not only a lack of support from medical peers and the need for secrecy, but also threats of violence, extortion and prosecution (5). In Bolivia and Chile, the interrogation of women seeking treatment for abortion complications in public hospitals is or has been routine (30,58). In Nigeria, illegal abortion carries a sentence of up to 14 years imprisonment except where the life of the woman is at risk (59). Moreover, in a number of countries, although illegal abortion has been tolerated in the past decade, arrests have been made without warning.

Safety is also about making sure that abortions are not carried out by clandestine and unskilled providers, who operate in situations which endanger women's lives, even if they have the best of intentions. A woman has little or no recourse when abortion is illegal, even if she is seriously injured, badly treated, refused pain relief, sent home in a poor condition, charged a large amount of money, or suffers any other form of negligence or malpractice. Women may need follow-up care, but they may be uncontactable because they have given a false address (60). Continuing pregnancies following attempts at self-induced abortion are not uncommon, e.g. some 18% of 803 women giving birth in a Brazil hospital had made unsuccessful attempts to abort (1) (61,62).

Good laws and policies on abortion, in addition to being legal instruments, are a sign of public acceptance of fertility control and of women's need for abortion. They signify an acceptance of the limitations of contraception and contraceptive use, and of women's right to decide the number and spacing of their children. Further, they mark respect for and acknowledgement of women's responsibility as mothers. Not least, they indicate a public health awareness of the costs of dangerous abortions, not only to women but also to their existing children, partners and families, and to health services and society as well.

Both the content of the law and the policy which defines how the law will be implemented also matter. It is often in the "details" that service delivery is facilitated or blocked. Both Zambia (63) and India (64) are often erroneously cited as examples of why changing the law does not matter, as both are classified as countries where abortion is "legal" but where abortion mortality remains high. However, the term "legal" does not mean the law is a good one for the circumstances in which it must be implemented. Abortion mortality remains high in India and Zambia because of obstacles to putting the law into practice, including provider unwillingness, lack of training for providers, failure to authorise providers and facilities, and a lack of resources for or commitment to delivering good services at primary care level.

In Zambia, the law requires several doctors' signatures for an abortion when in most places there are few or no doctors and a lack of resources. One study found that legal abortion services were either inaccessible or unacceptable to schoolgirls, among whom more than half of abortion deaths were occurring, because providers did not respect confidentiality. The young women were apparently required to reveal who made them pregnant, which they were unwilling to do, and they feared being expelled from school (63).

Abortion was legalised in India for broad social and medical reasons in 1972, when experience in providing safe abortions was more limited. Today, many of the annual 6.7 million abortions are still carried out by untrained providers in unapproved sites. Approved abortion clinics are concentrated in the cities, (64) and are unevenly distributed. Some l6-32% of approved primary health centres in four states have never offered abortions as they lack trained providers and functioning equipment. In one state, acceptance of sterilisation following abortion has been required (65), though this is not stipulated in law. Furthermore, women are often expected to attend without an appointment, and if the clinic is too busy they are told to come back another day, again without an appointment. Women may also be charged for the abortion according to the number of weeks of pregnancy, although the procedure is supposed to be free (TK Sundari Ravindran, Personal communication, 1997). Thus, women may be discouraged or prevented from seeking bonafide services in ways never intended by the law.

Changing laws and policies

To make abortion safe, restrictive abortion laws (including in some cases traditional and religious laws) in almost all countries will have to be annulled, amended or replaced (66). Countries have taken three main routes to this end: (1) liberalising the existing law within the penal or criminal code, (2) partially or fully legalising abortion through a positive law or a court ruling, or (3) decriminalising abortion by taking it out of the law altogether. These changes have already happened in almost all developed countries and are happening in a growing number of developing countries too.

Existing abortion laws reflect differing levels of commitment by the state to providing abortion and differing levels of state control over an abortion will be allowed (most commonly with medical professionals as gatekeepers) versus women's control. Laws may be enabling, intrusive or hindering in that sense. Thus, Sweden grants women the right to abortion upon their own request and provides services to implement that choice. Israel, on the other hand, limits individual discretion by requiring women to get the approval of an appointed committee for abortion, but provides all abortions that have been approved (67). Abortion mortality and morbidity tend to' be highest in countries where abortion laws are most hindering or restrictive. Many such laws are colonial in origin and are no longer operative in the countries that wrote them. Restrictive laws allow abortion only when a woman can be seen as a victim of circumstances, i.e. in cases of medical emergency, fetal abnormality, rape or incest (68). Yet the great majority of women need abortions for family planning reasons and on economic and social grounds.

The least fundamental form of abortion law reform is when limited grounds for abortion are added to an already restrictive criminal law. In Ghana, for example, a 1960 law allowed abortion only to save a woman's life, while a 1985 amendment allowed abortion to protect a woman's physical or mental health as well as on juridical and fetal impairment grounds (37). In 1995, however, unsafe abortions and high abortion mortality were still common in Ghana; (69) little had changed in practice.

Broader grounds may be added to an existing law to achieve partial legalisation. Malaysia now permits abortion within 120 days of conception when the continued pregnancy poses a threat to the woman's life or to her physical or mental health greater than if the pregnancy were terminated (70). As an induced abortion in the first trimester is always safer than pregnancy, this wording is open to liberal interpretation, as has occurred in Britain, but it may also be applied narrowly.

Canada is the only country to date that has decriminalised abortion entirely (37). In 1988, Canada's highest court struck down the federal law on abortion and it has not been replaced. Although there are abortion regulations at state level, any re-criminalisation of abortion would be illegal. This represents the most complete form of normalisation and de-politicisation of abortion possible, bringing it in line with all other medical procedures, and making good medical practice and quality of care in service provision the only issues involved. Any breaches of medical practice would be punishable under existing laws.

Who decides and when

The earlier in pregnancy an abortion takes place, the safer it is for the woman's health and the less complicated for the provider. Hence, on public health grounds, regulations that tend to delay the procedure should be avoided. Such regulations include putting the abortion decision into the hands of people other than the woman herself, weighting conscientious objection clauses in favour of providers who want to opt out, or requiring a waiting period between obtaining permission for and having an abortion.

In India the law requires a medical practitioner's authorisation for an abortion. In addition, the public health services in India sometimes ask women for their husbands' signature of consent, even though this is not required in law. In Punjab, the High Court allowed a man to divorce his wife on grounds of cruelty because she had had two abortions against his wishes, which implies acceptance of the husband's consent (64,65). In 14 countries, a husband must authorise his wife's abortion, (2) (37) and this can only be bypassed by a court or designated medical person, e.g. on health grounds. In contrast, South Africa's 1996 law stipulates that the only consent required for abortion is the woman's (40). Young women are required to have parental consent for abortion in 27 countries, most commonly in eastern and western European countries, but also in China, India (36) and some states in the USA. Again, consent may be waived with a court's authority, but this is very burdensome. Under the new South African law, on the other hand, a medical practitioner or registered midwife must advise a young woman to "consult with her parents, guardian, family members or friends" but abortion should not be denied if she does not (40).

In countries where safe abortions are the norm, more than 90% of women have abortions in the first trimester of pregnancy. (3) European laws (e.g. in France, Spain and Italy) commonly allow abortion upon the woman's request in the first trimester of pregnancy, while in the second trimester the permission of one or more doctors or a designated medical committee is required, and/or more restricted grounds pertain. Laws of this type were passed some 20-30 years ago, and along with good service delivery, have reduced abortion mortality and morbidity to a rarity (37). One of the unintended consequences, however, has been the creation of a minority of excluded women who have difficulty obtaining second trimester procedures who may have to travel to another country for them, as fewer clinics offer second trimester procedures (4) (71). Thus, obstacles and delays in obtaining an abortion after 12 weeks often make the procedure later and more complicated than necessary.

Women who need abortions after the first trimester of pregnancy include women who were not aware that they were pregnant or who denied the pregnancy until it began to show (most often young women), those who thought they were too old to get pregnant, those whose personal circumstances changed dramatically during the pregnancy (e.g. the husband leaves or dies), those who develop medical reasons for abortion and those who find out that the fetus is seriously damaged. Where abortion has previously been illegal and clandestine, women needing second trimester abortions also include those who were unaware that the law has changed, those living far from facilities, those who need more time to find out where to obtain a safe abortion, and those who have attempted self-abortion unsuccessfully and who have a continuing pregnancy.

Cuba is an early example of a developing country that legalised abortion on broad indications. In the context of sweeping changes in the country's health services in 1959, a 1936 law which had made abortion legal on grounds of serious risk to a woman's health was officially interpreted to encompass the WHO definition of "health" as a total state of well-being. Abortion services were extended to all obstetric-gynaecology hospitals. In 1979, when a new penal code was drafted, instead of specifying when abortion was legal, it specified when abortion was illegal. Under this code, abortion was determined to be illegal if it was carried out without the woman's consent, or in other than hospital premises, or if the provider failed to comply with established norms, or if it was carried out for profit. As there were hospitals throughout the country providing abortions free, these conditions did not create obstacles for women. Further, the law specified that menstrual regulation was not equivalent to abortion, as delay in menses may be due to causes other than pregnancy (72).

South Africa's new law is a more recent example, and has been accompanied by efforts to develop good service provision nationwide. However, it imposes incremental limits after the first trimester. It says that a pregnancy may be terminated upon the request of the woman during the first 12 weeks of pregnancy, but in weeks 13-20 must be approved by one medical practitioner, and after week 20, two medical practitioners (or one medical practitioner and a registered midwife) (40). These restrictions may prove problematic, especially in rural areas.

In Bangladesh, menstrual regulation (MR) is available only up to 10 weeks of pregnancy. A 1990 study of women seeking MR in Bangladesh found that almost 20% were turned away because they were over this time limit (73). Many others would not try to seek such services but go straight to an unregistered provider, probably an important source of continuing mortality and morbidity.

In Sweden, abortion is available at the woman's request up to 18 weeks of pregnancy and with the agreement of a medical board after that (74). This allows almost all abortions to be the woman's decision alone, a facilitating policy, which has developed on the basis of experience and an evolving awareness of women's needs on the part of medical professionals and policymakers.

A medical board and individual medical practitioners can be either supportive or restrictive. However, by putting the decision into the hands of anyone except the woman who is seeking an abortion, countries risk perpetuating the need for unregistered providers and unsafe procedures, thus maintaining the public health problem they hoped to reduce. The examples of Sweden and Canada show that criminal law and complicated restrictions on abortion are not necessary. They offer unambiguous models, worth emulating.

Striking a balance

Some laws stipulate that health professionals can refuse to participate in a legal abortion on grounds of conscience. In Britain, this is the case unless the woman's life is at risk. Moreover, no one applying for a gynaecology post in Britain can be asked their views on abortion as part of the job interview, even if abortion provision is in the job description. Providers can opt out for less than conscientious reasons, however, leaving women vulnerable and putting the onus on them to find a provider, which can be difficult and time-consuming (75).

Most ethical standards hold that a health care provider who refuses to provide an abortion on grounds of conscience has an obligation to refer the woman to someone who will. In South Africa, a draft of the new law made it mandatory for anyone with a conscientious objection to refer the woman to another provider, but this was omitted in the final text (76). The law says only that the woman shall be "informed of her rights" under the new law (40).

A balanced law would protect both a true conscientious objection and a woman's right to obtain a legal abortion without delay, including the right to be referred. Nevertheless, some advocates argue that health professionals have an obligation to perform all socially-sanctioned medical services, including abortion (77). Similarly, it can be argued that abortion services should be dedicated services and only those who are sympathetic to women's need for abortion should be employed in them, as a matter of quality of care and respect for women's feelings.

A certain proportion of women change their minds and decide to continue their pregnancy after having arranged for an abortion (78). This does not justify imposing a waiting period between arranging an abortion and having the procedure, as is the case in France and the Netherlands, where this regulation is also meant to keep women from other countries from travelling there for abortions.

Where counselling is to be provided, laws may specify what it should consist of and whether it is mandatory. Counselling can be directive, to try to influence or control a woman's decision. Anti-abortion organisations sometimes offer counselling services in some developed countries. In Singapore, the abortion law was liberalised in 1974 as part of national policy to encourage small families. In 1986, mandatory counselling was introduced in order to encourage those who could afford it to have more children, which led to a decrease in the number of abortions (79). In contrast, the aim of non-directive counselling, which is considered the most ethical form of counselling, is to help women to decide what is best for them. The new South African law says that the state shall promote "non-mandatory and non-directive counselling before and after the termination of pregnancy" (40).

In Viet Nam, very few women who have had abortions receive information on how to avoid future pregnancies, although they have indicated they would like to have such information. Some manage to find information elsewhere; others are left knowing as little as they did before their abortions (26). In Guyana, in contrast, the 1995 law stipulates counselling before and after abortion, stresses the importance of use of contraception, suggests including the woman's partner in counselling to foster male responsibility, and spells out in detail the content of counselling (alternatives to abortion, methods of abortion, possible adverse effects, contraception, STDs, psycho-social guidance). It even imposes a 48-hour waiting period before an abortion is carried out, to allow time for counselling (39). In the year after the law was changed, however, doctors' records showed that counselling was concentrated almost exclusively on offering contraception (57). This is not surprising in that these doctors were not trained as c ounsellors.

Striking a realistic balance and finding out what women require is advisable. Abortion services that are openly available have the opportunity to offer family planning and sexual health information and services, to give women the means to protect themselves. In developed countries, experience has shown that few women who seek an abortion actually need "counselling" as regards the abortion decision, but they do need information. This includes information before the abortion on the choice of abortion method and what happens during the procedure, and after the abortion information on possible complications and seeking help for these, what to do about resuming sex, prevention of HIV/STDs and the offer of a contraceptive method. The involvement of partners should be possible, but only at the woman's request, so as to protect her right to privacy.

Paying for safe abortions

Where abortion is clandestine and unsafe, women (or their partners or families) are buying drugs and other means of self-induced abortion and/or paying clandestine providers, while both public health services and women are paying for the treatment of abortion complications, often in tertiary level hospitals, where costs are highest. Costs (economic and social) incurred for unsafe abortions not only include acute care, however, but also the longer-term complications of damage to reproductive organs, pelvic inflammatory disease and secondary infertility. Moreover, the need for blood transfusions to deal with haemorrhage and other complications of unsafe abortion should be considered against a background of increasing HIV sero-prevalence in many developing countries. Costs to families, especially for a woman's existing children, also include those that result from a maternal death.

Unsafe abortion situations are characterised by a lack of equity in cost, safety and quality of care. In some Bolivian hospitals, women who present with signs of induced abortion are being charged higher fees for treatment of complications than women who appear to have miscarried, which contributes to delays in obtaining care (58). In Egypt, as elsewhere, the price for a clandestine abortion increases in proportion to the level of safety provided (80).

Most authors agree that treating abortion complications in sub-Saharan Africa consumes a disproportionate amount of hospital resources (50). In Bangladesh, up to 50% of hospital gynaecology beds are reported to be taken up with abortion complications. Women tend to wait until complications become severe before seeking help, increasing both the cost and complexity of treatment. Furthermore, women attending untrained providers have been found to make more visits for care and spend more overall than women attending trained providers in the first place (6). A Tanzanian study estimated that the cost per day of treating abortion complications, including the costs of drugs, meals, staying costs and surgical procedures, was more than seven times the Ministry of Health's annual per capita budget. Only three of 455 women were treated and discharged on the same day; 25% needed one day, almost 50% needed two days and the remainder needed 3-5 days more to recover (80). In Guyana, about 25% of the blood available at the ma in public hospital was used to treat abortion complications before the law was changed (57).

Covering the cost of safe abortions in public health services is therefore not about incurring entirely new costs, but about shifting expenditure away from complicated cases in tertiary level hospitals to safe, simple procedures which can be provided in primary clinics. Women may or may not be charged a fee at the point of service, but safety means affordability for the poorest of women as well as for those who can pay, with one high standard of care for all.

Requirements for safe abortions

Most developed countries still require that gynaecologists carry out abortions, yet this is not necessary, particularly not for abortions performed under 14 weeks of pregnancy, given that the skills needed have been greatly simplified and the rate of complications is so low (75). Instead, with appropriate training, nurse-midwives or those with comparable training would be the most appropriate abortion providers.

Training of trainers, equipment for and training in vacuum aspiration techniques and in how to provide medical abortions are needed. In many countries, one of the consequences of the longstanding illegality of abortion is that many providers are still using D&C and other outdated methods, which have not been in use in developed countries for many years, since they have a higher rate of morbidity.

In the past decade and more, MVA has been used to treat incomplete abortions following unsafe procedures in a growing number of developing countries and is considerably safer and less costly than D&C (82). In Nigeria, MVA has been used on an outpatient basis for most cases of abortion complications, reducing waiting time for women from 48-72 hours to 10-15 minutes (83). In addition to reducing mortality and morbidity from unsafe abortions, (84) vacuum aspiration can also be used for safe, early abortions up to 14 weeks of pregnancy - to prevent the consequences of unsafe abortions altogether. In South Africa, the training of midwives in MVA is a key activity of the new national abortion programme:

"The guidelines for training midwives prescribe a 160-hour course combining theory and clinical practicals. The curriculum includes an overview of the [law] and the problem of unsafe abortion, professional practice and ethics, communication skills and counselling techniques, patient assessment and preparation, pharmacology, the MVA technique, infection control, management of abortion complications, post-abortion family planning, emergency contraception, identification and treatment of sexually transmitted infections (STIs) and strategies for dual protection against unwanted pregnancy and STIs ..." (85).

First trimester abortions using surgical or medical methods (5) can be provided on an outpatient basis in primary care facilities; newer second trimester methods also require less skilled management than in the past (e.g. intravaginal misoprostol from 12-22 weeks of pregnancy) (86,87). Where STI prevalence is high among women seeking abortion, prophylactic antibiotic treatment prior to surgical abortion can prevent infection of the upper reproductive tract (88).

A study comparing medical abortion using mifepristone-misoprostol with early surgical abortion in China, Cuba and India, found medical abortion to be safe, efficacious and acceptable in a range of conditions (89). Fully established services for routine surgical abortion are not required prior to introducing medical abortion, although vacuum aspiration is a necessary back-up to both first and second trimester medical procedures for the small number of cases of incomplete abortion (90). It has been persuasively argued that medical abortion can be largely self-administered as long as the woman considers the method acceptable, is early enough in pregnancy (up to nine weeks LMP), can adhere to the protocol, is able to manage minor adverse reactions and seek help for more serious ones, can notice and cope with the expulsion of the embryo, and can recognise a complete abortion, return for a follow-up visit or use a home pregnancy test (91).

Along with safe methods and trained providers, programmes require locally accessible services in both rural and urban areas. In Zambia, gynaecologists were found to be a major obstacle to the setting up of safe abortion services (92). The ambivalence of doctors was also found to have hampered the implementation of a revised abortion law in Indonesia (41). In Bangladesh and India, untrained providers, who are often more easily accessible in rural areas, have never actively been stopped from practising (7,64). In South Africa, in contrast, as cases have arisen where unlicensed providers have continued to offer services despite the changed legal status of abortion, criminal charges have been pressed against them. A nationally co-ordinated programme in South Africa aims to ensure that throughout the country, primary and secondary care facilities are prepared to do abortions. All nine provinces in South Africa have developed provincial plans, each in collaboration with a medical school or a tertiary training hospi tal. A national advisory group has been set up to coordinate and monitor implementation of the new law, including health service managers, representatives from medical schools, academics and specialists, the nursing council, researchers and the non-governmental sector. This group was planning to meet every four to six months and make recommendations to government on relevant issues (85).

Quality of care

Bringing abortion services out into the open is a pre-condition for ensuring quality of care, accessibility, availability and affordability, especially for the poorest women. This encourages health professionals to provide a defensible service. In Guyana, for example, although most clandestine abortion providers before the law was changed in 1995 were medical professionals, septic abortion was the third highest cause (19%) of hospital admissions. After the law changed, this same group of abortion providers organised themselves and voluntarily began to give prophylactic antibiotics. Admissions to the main public hospital for septic and incomplete abortions fell by 41% within six months of this decision (57).

Public visibility in service provision means that women will have a more open choice of providers and can take action if their rights are violated or care is sub-standard. Legalisation also ensures that providers who attempt to sexually molest women seeking abortions can be prosecuted, anecdotally a not uncommon problem for women seeking clandestine abortions (57). Sympathetic treatment on the part of service providers is also important. Uncaring treatment and verbal abuse on the part of health care staff towards women seeking treatment for complications of clandestine abortion has been well documented in Latin America (29,51). Indeed, lack of sympathy is a problem in many countries, even those with safe abortion services such as Britain and the USA (81,93), where abortion has been legal for 30 years. South Africa is trying to confront this problem through workshops for service providers, to clarify values and increase empathy and respect for women with unwanted pregnancies (85).

Other ways to monitor and ensure quality of care include oversight by an independent national advisory body, decisions as to whether or not the procedure will be covered by national health insurance, the standards that approved institutions must meet, regulation of fees for services and requirements for record-keeping and the collection of data (57,85). In Guyana, data collection is required to include relevant demographic information about the woman, length of pregnancy, reasons for abortion, type of procedure, any complications and whether and what kind of contraceptive method was provided. Where deaths from dangerous abortions were previously high, and to ensure that the rate of deaths declines towards zero, the collection of baseline data (57) and regular audit of all reported abortion-related deaths, as part of broader maternal mortality audits, will reveal continuing risks, allowing discussion and action on reducing these risks. (6)

Guidelines for health service professionals are valuable for ensuring equity of access and quality of care. The UK Royal College of Obstetricians and Gynaecologists recently published evidence-based guidelines that cover organisation of services, information for women, pre-abortion assessment, abortion procedures, management of complications and after-care (94).

Raising public awareness

Although abortion has been legal in India since 1972, interviews with 67 women in rural Maharashtra in 1997 found that only 18% knew that this was the case, while 64% thought it was not and the remainder were unsure. Even those who knew it was legal sometimes had inadequate or incorrect information about whether husband's consent was needed, eligibility for abortion and the time limits within which abortion is permitted (64).

In Puerto Rico, although abortion has been legal for 20 years (a consequence of its commonwealth status with the USA), there is still a widespread perception that abortion is illegal. Public information on where women can get an abortion is very limited, and clinics still use euphemisms to suggest that abortion services are provided. Medical students also know very little about what is permitted (95).

In Mozambique, although abortion has not been legalised as such, safe terminations have been available at the main hospital in Maputo since 1981 in order to reduce mortality from unsafe abortions. However, a study reported in 1997 found that young women who had recently migrated to the city, who did not have a steady partner, who were from poorer socio-economic groups, who did not use contraception and who had no previous abortions were less likely to know that they could obtain a safe abortion at that hospital. They were more likely to seek clandestine abortions and experience complications, for which they went to that same hospital. Thus, the women who were most at risk were also the ones who had the least information (96).

Hence, widespread public awareness is an important component in making abortion safe where it has previously been unsafe; women need to know that safe abortions are not only permitted but available.

Conclusions

Much can be done despite the difficulties of changing national abortion laws. Women's health groups and other advocates, parliamentarians and health professionals can work together to support the right of women not to die from unsafe abortions and to ensure that they receive treatment for complications. They can urge hospitals not to report women and legitimate service providers to the police, as well as advocate for the decriminalisation of abortion. In countries where the letter of the law is not a primary obstacle, they can also campaign for a choice of safe abortion methods, improvements in regulations governing the registration of providers and facilities, and for better training for providers. Additionally, they can monitor accessibility, affordability and quality of care in these services (97,98).

Committed doctors can make an important difference, e.g. providing treatment for women with abortion complications (99), interpreting the law in a liberal way and providing safe services where they are legal (92), and training providers in the safest techniques to reduce mortality and morbidity (96,100). Even where legal change has not taken place or is not likely to happen quickly, improvements in abortion methods used and in the responsiveness of providers to the demand for safer abortions may improve the situation to some extent. Furthermore, courts can pass judgements that result in shorter prison sentences and fewer prosecutions of women for having abortions, and help to open the way to law reform. This occurred in Nepal in the 1990s (101), as it did in countries like Spain in the 1970s.

Abortion law reform is a necessary condition for making abortion safe, though it is not sufficient in itself. Women remain vulnerable where safe abortion is not legally sanctioned, because quality of care cannot be assured, abuses cannot be challenged and both women and providers remain at risk of prosecution, blackmail, and social and professional stigma. The dedication of individuals to providing treatment for abortion complications or safe abortions in a context of clandestinity, as important as it is, cannot make up for the absence of a legal framework and national programmes. In the long run, abortion needs to be decriminalised in order for it to be safe.

Although law and policy and women's rights are central to this issue, making unsafe abortions safe is above all a public health responsibility of governments. Moreover, reducing maternal mortality by making abortions safe is an important part of the international commitment made in Cairo in 1994 and re-affirmed at the Cairo+5 meeting in 1999. The practical steps to bring about the changes outlined in this article could be achieved by most countries in a few short years once they have committed themselves to making abortions safe.
Table 1

Mortality from unsafe abortions [3]

Region Mortality per 100,000
 abortions

Africa 680
South and Southeast Asia 283
Latin America 119
Developing countries 400
Developed countries 0.2-1.2


(1.) A recent study of abortion failure after misoprostol use in Brazil in 42 infants with congenital abnormalities found these to be consistent with vascular disruption in the fetus in utero caused by contractions from the prostaglandin; however, the association needs to be confirmed. See (62).

(2.) The 14 countries are Egypt, Syria, United Arab Emirates, Kuwait, Morocco, Iraq, Saudi Arabia, Turkey, Nicaragua, Republic of Korea, Japan, Taiwan, Malawi and Guinea-Bissau. See (37).

(3.) Weeks of pregnancy are sometimes measured from first day of last menstrual period (LMP) and sometimes from the estimated date when conception probably took place, which is about two weeks later. Sources are not always clear about the distinction. Abortions using vacuum aspiration can be done up to 14 weeks LMP.

(4.) Some 2000 women from outside Britain had an abortion in England and Wales in 1997, almost all of them from countries where there is a first trimester limit for on-request abortions.

(5.) Surgical abortion here refers to vacuum aspiration and MVA. Medical abortion refers to the combination of mifepristone and a prostaglandin, either gemeprost (which requires refrigeration) or misoprostol (which does not), or a prostaglandin alone.

(6.) The audits entitled confidential Enquiry into Maternal Deaths in the UK are published every three years by Her Majesty's Stationery Office, London.

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Marge Berer *

* Making abortions safe: a matter of good public policy and practice. Bulletin of World Health Organization 2000, 78(5):580-89.
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