Interventions to Reduce Unsafe Abortions and Their Consequences

Even if all the interventions described above were imple­mented, some abortions would still occur as long as peo­ple are unable to fully anticipate what will happen in their lives and as long as contraceptive methods are not 100% effective. Therefore, other than diminishing the number of induced pregnancy terminations, unsafe abortion can be reduced by making safe all abortions that will still occur in the foreseeable future.

Decriminalizing or Extending Legal Grounds for Abortion. As described earlier, most legal abortions are safe while the vast majority of illegal abortions are unsafe. Conse­quently, the most effective approach to reducing unsafe abortions is to eliminate the laws that penalize the volun­tary termination of pregnancy.

The reduction of unsafe abortion and its consequences following the liberalization of abortion laws has been documented in several countries. For instance, during the 3 years after the approval of the Abortion Act (1982 and 1984), which extended the legal grounds for abortion and greatly facilitated free access to safe abortion in England and Wales, no deaths related to induced abortion were registered, compared with 75-80 deaths per triennium before the act was passed (Stephenson et al, 1992).

A 50% reduction in the abortion-related maternal death rate was observed in the state of New York during the 2 years after the 1970 liberalization of abortion laws.

A dramatic decrease in abortion-related maternal mortal­ity was also observed in the whole of the United States following the Supreme Court’s 1973 Roe v. Wade decision (Cates et al, 2003).

We have already described the negative health effect of the criminalization of abortion, dramatically illustrated by the increase in maternal mortality after the prohibition of both abortion and contraceptives in Romania in late 1965. Even more dramatic was the reduction in abortion-related maternal mortality after the decriminalization of abortion and contraception following the fall of the Romanian leader, Nicolae Ceausescu, in December of 1989: The maternal mortality ratio fell from approximately 150 per 100 000 live births in the previous year to fewer than 50 per 100 000 live births 2 years after decriminalization (Stephenson et al., 1992).

Improving Access to Legal Abortion. The experience of countries such as India, South Africa, and Zambia has shown that the decriminalization of abor­tion does not guarantee easy access to safe procedures. In India and Zambia, and (to a lesser degree) South Africa, the majority of women still do not have access to safe abortion services. In these countries, it is essential to accelerate the process of adapting and upgrading the public health system to meet the demand for voluntary pregnancy termination.

In a much larger number of countries, the restricted laws permit abortion under specific circumstances, but women who fulfill these requirements still may not have access to safe pregnancy termination and may have to resort to highly unsafe, back-street abortions. In these countries, access to safe abortion greatly depends on how liberally or restrictively the law is interpreted. A crucial role is played by obstetricians/gynecologists, since ulti­mately they are the ones who decide whether or not to perform the abortion, and by the legal profession, whose function it is to interpret the law.

Improving access to safe abortion to the full extent permitted by law is an important means for reducing the rates and consequences of unsafely induced abortion. Despite current efforts, a large number of women around the world who meet the requirements to have access to safe and legal abortion are still denied their right.

Access to Postabortion Care. The mortality rates and severity of short- or long-term complications of unsafe abortion may be strongly influ­enced by the quality of the care received after the abor­tion. Acute complications such as uterine perforation or the perforation or injury of other internal organs may be fatal if emergency care is not urgently provided. Infection will progress locally and systemically as long as the proper medical and surgical therapy is not given.

The later and the less efficient the care received, the more severe the consequences are likely to be and the greater the risk of death. Therefore, it is recommended that the assessment of the woman’s condition and the provision of postabor­tion care should be available on a 24-h basis and provided with the urgency demanded by the severity of the condi­tion. Accordingly, the governments represented at the 1994 ICPD Conference agreed that ‘‘in all cases, women should have access to quality services for the management of complications arising from abortion.’’

Unfortunately, the prevalent discrimination against women who have induced abortions has frequently led to inadequate emergency care. Delay in receiving care can be attributable to lack of services within a reasonable distance of the woman’s residence or lack of roads or means of transportation, but may also be the result of social, economical, religious, or legal restrictions on abortion.

Sev­eral studies carried out in countries with restrictive abortion laws have found that, in some hospitals, particularly those run by the Catholic Church, women suspected of having had an induced abortion were turned away. In Chile, many women were jailed after being denounced by personnel at the hospital where they received postabortion care, effec­tively inhibiting women from seeking the medical assistance they needed. Thus, access to postabortion care may be limited by providers in at least two ways: By direct rejection or by threat of prosecution.

Postabortion care should not, however, be limited to the emergency situation, but should take into consider­ation the long-term needs of women, including counseling and services for the prevention of later unwanted preg­nancy and abortion. Several decades ago, it was shown already that women who have had an abortion are at a much higher risk of aborting the next pregnancy than those who never had an abortion, and more recent studies have shown the effectiveness of postabortion contracep­tion in reducing future unplanned pregnancies and abor­tions (Johnson et at., 2002).

Conclusions.While there exists universal agreement on the need to reduce the number of abortions and their consequences, many governments in developing and developed countries have still not fully adopted the necessary policies to promote practices that could prevent abortion. The deaths of thousands of women that result from unsafe conditions in which abortion is practiced in the poorer regions of the world are preventable, as the causes of abortions and the interventions that could reduce their numbers and the severity of their consequences are well known.

It is the obligation of international organizations and of all of those dedicated to the health and well-being of women to promote the implementation of the measures that would decrease the number of abortions and increase women’s access to safe abortion services and to the means to avoid unwanted pregnancy.

We expect the current trend toward a reduction in the number of abortions to continue, but it depends on the public health community and donors realizing that access to family planning infor­mation and services is still very limited, particularly in Africa and the more vulnerable communities in Latin America and parts of Asia, and deserves more attention than it has received in recent years.

There has also been a trend toward liberalization of abortion laws in some large countries, while more restricted laws have been imposed in a couple of countries. A better understanding of the ineffectiveness of restrictive laws in reducing the number of abortions and the heavy consequences on health and well-being, unfairly borne almost exclusively by poor, young, and rural women, should progressively lead the world community to take the logical steps to reduce this human drama and public health burden: Improving education and services in sexuality and contraception; greater social support to women who want to have a baby, but are abandoned by their partner and family; and more liberal abortion laws broadly implemented without social, economic, or age limitations.

Great prog­ress in all these areas should take place in the next 7 years to achieve the Millennium Development Goal of reducing by three-quarters the maternal mortality ratio in the world.