Complications and Consequences of Unsafe Abortion

Unsafe abortions are commonly associated with a range of complications that can lead to mortality, morbidity, and permanent disabilities, such as chronic pelvic pain, pelvic inflammatory disease, infertility, and genital fistula.

In contrast, when abortion procedures are performed appropriately by trained providers, complications rarely occur. In fact, the risk of death after a legal, safe abortion in the United Stated is ten times lower than the risk of death after childbirth (0.7 vs 7.0/100 000).

Acute Complications. The most frequent immediate complications of unsafe abortion are hemorrhage, infection, traumatic or chemical lesion of the genitals and other organs, and toxic reactions to products ingested or placed in the genital tract.

Hemorrhage, which can lead to acute anemia, shock, and death, frequently necessitates an emergency blood transfusion. In countries with a high prevalence of HIV and inadequate facilities for testing donated blood, blood transfusion may result in HIV infection.

Bacterial infec­tions may be introduced into the uterus during the man­euvers to procure an abortion and can be disseminated to the fallopian tubes, the ovaries, and the abdominal cavity, causing pelvic inflammatory disease and peritonitis. Infec­tions can also disseminate through lymphatic channels or through the blood, leading to sepsis and septic shock, which frequently ends in the woman’s death.

Long-Term Sequelae. Women may suffer sequelae of unsafe abortion through two different mechanisms: The treatment required to prevent death may include the removal of the ovaries, the fallopian tubes, and the uterus, rendering the woman infertile, or the consequences ofinfection or trauma to the reproductive tract may also lead to infertility or risk of ectopic tubal pregnancy. Ectopic pregnancy may be fatal if immediate access to treatment is not available.

Chronic inflammation of the internal genital organs or surgical scars may result in chronic pelvic pain, which can interfere with a woman’s daily activities, including sexual intercourse. These chronic sequelae may have severe social consequences.

Maternal Mortality. It is estimated that roughly 13% of the 527 000 or more maternal deaths occurring worldwide every year are the result of complications of unsafe abortions (World Health Organization, 2004). This means that close to 70 000 women die every year following unsafely induced abor­tion. In many countries, abortion is the third or fourth most frequent cause ofmaternal death but in some, unsafe abortion is the most common cause of maternal death. Up to 98% of all abortion-related deaths occur in developing countries, where abortion is mostly illegal and therefore unsafe. Unsafe abortion related mortality rates per 100 000 live births, by region, are presented in Figure 2.

Figure 2. Mortality due to unsafe abortion per 100 000 livebirths according to geographical region. Excluding Japan, Negligible. Adapted from World Health Organization (2004) Unsafe Abortion: Global and Regional Estimates of Incidence of Unsafe Abortion and Associated Mortality in 2000, 4th edn. Geneva: World Health Organization

Psychological Consequences. Reviews of the literature on the psychological conse­quences of induced abortion carried out over the last 30 years have found that adverse psychological sequelae occur in only a small percentage of women (Rogers et al, 1989). More frequent and severe negative psychological effects have been described among women who are denied abortion and among the children who are born as a result (David, 2006).

Several studies have identified some factors associated with a greater risk of suffering psychological symptoms following induced abortion; these factors include having suffered the same symptoms prior to the abortion, having been under pressure to abort from partners or others, or, conversely, having experienced external cultural-religious pressure not to abort (Major et al., 1998) or to terminate a wanted pregnancy because a genetic fetal defect was diag­nosed.

The unanimous conclusion of a panel of experts assembled by the American Psychological Association to examine legal abortion in the United States was that pregnancy termination has no negative psychological con­sequences for women who make the decision with no exter­nal pressure and that there was no evidence to support the purported existence of a so-called abortion trauma syn­drome (American Psychological Association, 2005).

A more recent paper analyzed a cohort of women aged 15-25 years and controlled for a number of potentially confounding factors existing before abortion. The authors found a significantly greater risk of psychological disorder among women who had induced abortion than among those who had live births and those who were never preg­nant (Fergusson et al., 2006).

They accept, however, that ‘‘an important threat to the study validity comes from the lack of information on contextual factors associated with the decision to seek an abortion.’’ In fact, they controlled only for the first of several factors listed above and, consequently, did not invalidate the conclusions of the American Psychological Association. In summary, abortion may lead to psychological consequences if it is not the woman’s free, informed decision, taken without external pressure either in favor or against pregnancy termination.

Economic Consequences. A safe abortion, carried out in a clinic or hospital envi­ronment, costs less than the average delivery, while the cost of caring for the complications resulting from an unsafe abortion is far greater and has put a heavy burden on the health system of many developing countries. The care of women with complications resulting from unsafe abortions can consume a large proportion of hospital beds, operating room time, medical equipment, antibio­tics, intravenous fluids, blood and blood products, dispos­able supplies, and skilled human resources.

For instance, the cost of treating a patient for complications resulting from an unsafe illegal abortion was nine times higher than the cost of a safe abortion and five times higher than the cost of delivery care in the main hospital of Maputo, Mozambique, in 1993. Use of antibiotics was 100 times greater, blood transfusions 16 times more frequent, and the duration of hospitalization was 15 times longer in women treated for complications resulting from unsafe abortion than for women who underwent in-hospital preg­nancy termination (Hardy et al., 1997).