Unsafe Abortion Mortality: New Estimates and Trends, Health and Social Consequences

1. Unsafe Abortion Mortality: New Estimates and Trends, Health and Social Consequences Presented at the International Interdisciplinary Symposium on Reducing Maternal Mortality in sub-Saharan Africa: better understanding for better action Dakar, Senegal – December 13-16, 2010 Professor FE Okonofua University of Benin, Nigeria

2. Background • The WHO defines Unsafe Abortion as: “A procedure for terminating an unintended pregnancy that is carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both¨ • Despite increasing prevalence of contraception and the existence of safe and effective methods of abortion, millions of unsafe abortion continue to take place globally each year resulting in increased risks of associated morbidity and mortality • The objective of this presentation is to provide the most recent WHO estimates of unsafe abortion and to elucidate the associated health and social consequences

3. Methodology • Review of the most recent WHO publications and database on unsafe abortion and associated mortality • Review of other publications relating to trends in abortion incidence and mortality • Recent papers published by Shah and Ahman in Reproductive Health Matters and Susheela Singh in the Lancet

4. Unsafe Abortion in 2008 • WHO estimates that 21.6 million unsafe abortions took place worldwide in 2008, almost all in developing countries • The best indicators for measuring unsafe abortion are: - Unsafe abortion rate: the number of unsafe abortions per 1000 women aged 15-44 years - Unsafe abortion Ratio: the number of unsafe abortions per 100 live births

5. Estimated Annual Incidence of Unsafe Abortion per 1000 Women Aged 15-44 years, by UN Sub-region, 2008

6. Contd

7. Estimated Annual Number of Unsafe Abortions, Rates and Ratios, By Geographical Regions, 2008

8. Unsafe Abortion Rates Per 1000 Women of Ages 15-44 For All Countries

9. Estimated Number of Unsafe Abortion Globally and by Major Regions, 2003 and 2008

10. Unsafe Abortion Rates Per 1,000 women

11. Consequences of Unsafe Abortion • Despite being a simple procedure, one in four women having an unsafe abortion face the risk of severe complications • Worldwide, unsafe abortion account for 13% of maternal deaths, and 20% of overall burden of maternal death and longer term disability as measured in Disability Adjusted Life-Years (DALYs) • Compared with developed countries the burden per 1000 unsafe abortions is more than six times as high in sub-Saharan Africa and four times as high in Asia

12. Consequences of Unsafe Abortion • Unsafe abortions accounted for 20,500 maternal deaths in 2005 • Among the estimated 358,000 global maternal deaths in 2008, 47,000 were due to complications of unsafe abortion (nearly a doubling) • Over half of these were in Africa, while 34% occurred in the least developed countries • MMR associated with abortion was 650 deaths per 100,000 unsafe in 2003 , compared to 10 per 100,000 in developed countries

13. 36% The World’s Population Live Where Abortion is Very Restricted

14. Restricting Contraception and Legal Abortion In Romania Resulted In Increased Maternal And Abortion-related Deaths

15. Distribution of Countries by Number of Deaths due to Unsafe Abortion Number of deaths per 100 000 live births

16. Distribution of Countries By Number of Deaths Due to Unsafe Abortion

17. Estimates of Deaths due to Unsafe Abortion in 2005 in three countries

18. Health Consequences Are Often Severe And Can Be Long-term • Kenya: 28% of post-abortion patients experienced severe complications • Nigeria: among hospitalized patients, one in 3 had hemorrhage, one in four sepsis and about 1 in 10 had injury to other organs • Abortion in the second trimester greatly increases risk • There are many long-term consequences

19. Additional Consequences • Loss of productivity • Increased economic burden and cost to the public health system • Social & cultural stigma • Long term ill-health, including infertility • Overall , some 24 million women are estimated to be currently suffering from secondary infertility due to unsafe abortion

20. Contraception is Key to Prevention Of Unsafe Abortion • It is well documented that family planning programs reduce abortion • There can be a lag: the desire for small families may increase faster than contraceptive use • But contraception does not eliminate the need for safe abortion, and there are several other reasons why women result to abortion • Governments and stakeholders must improve access to contraceptive information and services

21. Prevention of Unsafe Abortion Includes More than Contraception • Access to safe and legal abortion is the most fundamental means of prevention • Also important are use of safer techniques and training of providers in these techniques • Manual vacuum aspiration is effective and suitable for low resource settings • Early medication abortion is a new and recommended technique

22. Prompt And Appropriate Treatment Of Complications Is Also Important • WHO has issued guidelines for provision of safe abortion care & treatment of complications • Post abortion contraceptive counseling and services are essential • Rapid transfer to tertiary care can be lifesaving

23. The Public Health Imperative • The rationale for making safe abortion available is well established • The public health record is clear and incontrovertible: access to safe, legal abortion improves health • Cairo, 1994:”In circumstances where abortion is not against the law, such abortion should be safe.”

24. Dealing with Unsafe Abortion in Africa The Maputo Plan of Action • Enact policies and laws to reduce the incidence of unsafe abortion • Prepare and implement national POA to reduce the incidence of unwanted pregnancies & unsafe abortion • Provide safe abortion services to the fullest extent of the law • Educate communities on available safe abortion services as allowed by natural laws • Train health providers in prevention and management of unsafe abortion

25. MahmoudFathalla Sums Up The Situation Very Well “Pregnancy-related deaths are often the ultimate tragic outcome of the cumulative denial of women’s human rights. Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.” Simply put, they die because they do not count.

26. Some References: • Shah H, Ahman E. Unsafe abortion: global and regional incidence, trends, consequences and challenges. J Obstet Gynecol Can 2008; 31: 1149-1158. • Singh S. Hospital Admissions resulting from unsafe abortion: estimates from 13 developing countries. Lancet 2006; 368: 1887-1892. • Grimes D, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, Shah IH. Unsafe abortion: A preventable pandemic. Lancet 2006 (Special Edition): 65-76. • Sedgh G, Henshaw S, Singh S, Ahman E, Shah IH. Induced abortion: estimated rates and trends worldwide. Lancet 2007, 370, 1338-1345

27. Acknowledgements • Dr Alain Prual of UNFPA, and Dr Brooke Levandowski of Ipas, USA For sharing some of the reading materials with me.

28. Thank you Merci