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Unsafe abortion

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Soviet poster c. 1925. Title translation: "Abortion induced by either self-taught midwife or obstetrician not only maims the woman, but also often leads to death."

An unsafe abortion is the termination of a pregnancy by people lacking the necessary skills, or in an environment lacking minimal medical standards, or both.[1] An unsafe abortion is a life-threatening procedure. It includes self-induced abortions, abortions in unhygienic conditions, and abortions performed by a medical practitioner who does not provide appropriate post-abortion attention.[2] About 25 million unsafe abortions occur a year, of which most occur in the developing world.[3]

Unsafe abortions result in complications for about 7 million women a year.[3] Unsafe abortions are also one of the leading causes of deaths during pregnancy and childbirth (about 5–13% of all deaths during this period).[3] Most unsafe abortions occur where modern birth control is unavailable,[4] or in developing countries where affordable and well-trained medical practitioners are not readily available,[5][6] or where abortion is illegal,[7] with the more restrictive the law, the higher the rates of death and other complications.[8]

Overview

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The World Health Organization (WHO) estimated that for the time period of 2010-14 there were 55.7 million abortions worldwide each year. Out of these abortions, approximately 54% were safe, 31% were less safe, and 14% were least safe. That means that 25 million (45%) abortions each year between 2010 and 2014 were unsafe, with 24 million (97%) of these in developing countries.[9] In 2003 approximately 42 million pregnancies were voluntarily terminated, of which 20 million were unsafe.[10] According to WHO and the Guttmacher Institute, at least 22,800[11] women die annually as a result of complications of unsafe abortion, and between two million and seven million women each year survive unsafe abortion but sustain long-term damage or disease (incomplete abortion, infection, sepsis, bleeding, and injury to the internal organs, such as puncturing or tearing of the uterus). They also concluded abortion is safer in countries where it is legal, but dangerous in countries where it is outlawed and performed clandestinely. The WHO reports that in developed regions, nearly all abortions (92%) are safe, whereas in developing countries, more than half (55%) are unsafe. According to WHO statistics, the risk rate for unsafe abortion is 1/270; according to other sources, unsafe abortion is responsible for at least 8% of maternal deaths.[12][11] Worldwide, 48% of all induced abortions are unsafe. The British Medical Bulletin reported in 2003 that 70,000 women a year die from unsafe abortion.[13] Incidence of such abortions may be difficult to measure because they can be reported variously as miscarriage, "induced miscarriage", "menstrual regulation", "mini-abortion", and "regulation of a delayed/suspended menstruation".[14][15]

An article pre-printed by the WHO called safe, legal abortion a "fundamental right of women, irrespective of where they live" and unsafe abortion a "silent pandemic".[14] The article states "ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative." It also states "access to safe abortion improves women's health, and vice versa, as documented in Romania during the regime of President Nicolae Ceaușescu" and "legalisation of abortion on request is a necessary but insufficient step toward improving women's health" citing that in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. WHO's Global Strategy on Reproductive Health, adopted by the World Health Assembly in May 2004, noted: "As a preventable cause of maternal mortality and morbidity, unsafe abortion must be dealt with as part of the MDG on improving maternal health and other international development goals and targets."[16] The WHO's Development and Research Training in Human Reproduction (HRP), whose research concerns people's sexual and reproductive health and lives,[17] has an overall strategy to combat unsafe abortion that comprises four interrelated activities:[16]

  • to collate, synthesize and generate scientifically sound evidence on unsafe abortion prevalence and practices;
  • to develop improved technologies and implement interventions to make abortion safer;
  • to translate evidence into norms, tools and guidelines;
  • and to assist in the development of programmes and policies that reduce unsafe abortion and improve access to safe abortion and high-quality post-abortion care.

A 2007 study published in The Lancet found that, although the global rate of abortion declined from 45.6 million in 1995 to 41.6 million in 2003, unsafe procedures still accounted for 48% of all abortions performed in 2003. It also concluded that, while the overall incidence of abortion in both developed and developing countries is approximately equal, unsafe abortion occurs more often in less-developed nations.[18] The most repressive of laws still apply to over 40% of the world population. If found out, these women may face prosecution, and later incarceration. [19]

According to a new study in The Lancet that focused on data from 2010 to 2014, nearly 55 million pregnancies are terminated early and of that 55 million, nearly half, 25.5 million are deemed as unsafe.[20] The WHO and the Guttmacher Institute stress the need for access to a safe abortion for all women and that unsafe methods must be replaced. Africa, Asia and Latin America account for almost 97 percent of unsafe abortions. These regions are often poorer and underdeveloped and lack the access to safe abortion methods. Out of all abortions in these regions only 25% are considered safe. In developed countries these numbers improve drastically. Nearly all abortions in North America (99%) are considered safe. Overall nearly 88% of abortions in developed countries were actually considered safe, with the number of safe abortions in Europe slightly lower.

Conflating illegal and unsafe abortion

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Unsafe abortions often occur where abortion is illegal.[7] However, the prevalence of unsafe abortion may also be determined by other factors, such as whether it occurs in a developing country that has a low level of competent medical care.[6]

Unsafe abortions sometimes occur where abortion is legal, and safe abortions sometimes occur where abortion is illegal.[21] Legalization is not always followed by elimination of unsafe abortion.[5][22] Affordable safe services may be unavailable despite legality, and conversely, women may be able to afford medically competent services despite illegality.[23]

When abortion is illegal, that generally contributes to the prevalence of unsafe abortion, but it is not the only contributor. In addition, a lack of access to safe and effective contraception contributes to unsafe abortion. It has been estimated that the incidence of unsafe abortion could be reduced by as much as 73% without any change in abortion laws if modern family planning and maternal health services were readily available globally.[4]

Illegality of abortion contributes to maternal mortality, but that contribution is not as great as it once was, due to medical advances including penicillin and the birth control pill.[24]

Frequency by continent

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Region Number of unsafe abortions (thousands) Number of unsafe abortions per 100 live births Number of unsafe abortions per 1000 women
Africa 4200 14 24
Asia* 10500 14 13
Europe 500 7 3
Latin America and the Caribbean 3700 32 29
North America Negligible incidence Negligible incidence Negligible incidence
Oceania ** 30 12 17
World 19000 14 14
* Excluding Japan
** Excluding Australia and New Zealand

Source: WHO 2006[25]

Abortion in the U.S. before 1973 (Roe v. Wade)

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In 1973, the Supreme Court ruled 7–2 that laws prohibiting an abortion violated a woman's right to privacy. The landmark case, Roe v. Wade, changed abortion law in the United States.

Early abortion laws generally only prohibited the use of toxic chemicals that were used to cause a miscarriage. The first such law was passed in Connecticut in 1821.[26]

Prior to 1973, the authority to legalize abortion rested with the state governments. Up through the 1960s, 44 states had laws that outlawed abortions unless the health of the pregnant patient was at stake.[27]

In the 1940s, records show that more than 1,000 women died each year from abortions that were labeled as unsafe. Many of these abortions were self-induced. Unsafe abortion practices were such a concern in the United States that nearly every large hospital had some type of "septic abortion ward" that was responsible for dealing with the complications that accompanied an incomplete abortion. Incomplete abortions were the leading cause for OB-GYN services across the United States. In the 1960s, the National Opinion Research Center found that hundreds of women were attempting to self-abort with coat hangers, knitting needles and ballpoint pens, and by swallowing toxic chemicals like bleach and laundry detergent.[28] However, the number of deaths declined significantly into the 1960s and 1970s. The Centers for Disease Control and Prevention estimates that in 1972, 130,000 women attempted self-induced abortions or obtained illegal abortions, resulting in 39 deaths.[29]

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In 2005, the Detroit News reported that a 16-year-old boy, at his pregnant, under-age girlfriend's request, repeatedly beat her abdomen with a bat to abort the fetus. The young couple lived in Michigan and were evading a state law requiring a minor to receive a parent's or a judge's consent to obtain a legal abortion.[30][31][32] In Indiana, where there were also parental consent laws, 17-year-old Becky Bell died from an unsafe abortion in 1988 rather than discuss her pregnancy and wish for an abortion with her parents.[33][34] [better source needed]

Methods

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Methods of unsafe abortion include:

Health risks

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Unsafe abortion is a major cause of injury and death among women worldwide. It is estimated that nearly 25 million unsafe abortions take place annually.[9] WHO estimates that at least 7.9% of maternal deaths are due to unsafe abortion, with a greater proportion occurring in Latin America, the Caribbean, and sub-Saharan Africa and a lesser proportion in East Asia where access to abortion is generally legal.[40] 97% of these abortions take place in developing countries.[41] Unsafe abortion is believed to result in at least 22,800 deaths and millions of injuries annually.[41] The legal status of abortion is believed to play a major role in the frequency of unsafe abortion.[42][43] For example, the 1996 legalization of abortion in South Africa had an immediate positive impact on the frequency of abortion-related complications,[44] with abortion-related deaths dropping by more than 90%.[45] Groups such as the World Health Organization have advocated a public-health approach to addressing unsafe abortion, emphasizing the legalization of abortion, the training of medical personnel, and ensuring access to reproductive-health services.[43]

An unsafe abortion can lead to wide range of health risks that can affect the well-being of women. The major and most life-threatening complications that stem from unsafe abortions are infection, hemorrhaging and injury to internal organs.[46]

Abortion symptoms that can lead to additional health risks:

  • To provide the necessary treatment, an accurate assessment of an unsafe abortion is critical. Some signs and symptoms that require immediate attention by a licensed health care provider include: abdominal pain, vaginal infection, abnormal vaginal bleeding, shock (collapse of the circulatory system).[46]
  • It is difficult to diagnose complications that result from an unsafe abortion. A woman with an extra-uterine or ectopic pregnancy may have symptoms similar to those of incomplete abortion. Therefore, it is important for health care providers to refer individuals they are unsure about to a facility where a definitive diagnosis can be made and care can be provided.[47]

Complications and their treatments include:

  • Infection: antibiotics prescribed by a health care provider and removing tissue from the affected area.
  • Hemorrhage: swift treatment by a health care provider is imperative, as delays can be fatal.

Damage to the genital tract or internal organs: Admission to a health care facility is imperative, any delay can be fatal.[8]

Treatment of complications

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Regardless if an abortion was legal or illegal, health care providers are required by law to provide medical care to patients, as it may be life-saving. In some cases, treatment for abortion complications may be administered only when the woman provides information about the abortion and any and all persons that were involved.[48] In areas where abortion is illegal, people seeking care for complications of illegal abortions may face legal consequences. This may deter people from seeking life-saving care.[48]

Globally, there is a high burden of complications from unsafe abortions.[49] The costs of treating the complications can be significant in developing countries, where, in 2011, 98% of unsafe abortions occurred.[50] An estimated 5.3 million women worldwide have developed complications or disabilities from unsafe abortion, which may be either temporary or permanent.[51] Unsafe abortions cause an estimated 5 million lost disability-adjusted life years each year by women of reproductive age.[52]

See also

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References

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  1. ^ Safe Abortion: Technical and Policy Guidance for Health Systems. World Health Organization. 2003. p. 12. ISBN 9789241590341. a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skill or in an environment lacking the minimum medical standards, or both.
  2. ^ "Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003" (PDF). World Health Organization. 2007. Retrieved March 7, 2011. The estimates given in this document are intended to reflect induced abortions that carry greater risk than those carried out officially for reasons accepted in the laws of a country.
  3. ^ a b c "Preventing unsafe abortion". www.who.int. Retrieved 19 April 2019.
  4. ^ a b Singh S, Darroch JE, Ashford LS, Vlassoff M (2009). Adding it Up: The Costs and Benefits of Investing in Family Planning and Newborn Health (PDF). New York: Guttmacher Institute and United Nations Population Fund. If women's contraceptive needs were addressed...the number of unsafe abortions would decline by 73% from 20 million to 5.5 million. A few of the findings in that report were subsequently changed, and are available at: Facts on Investing in Family Planning and Maternal and Newborn Health (PDF). Guttmacher Institute. 2010. Archived from the original (PDF) on 2012-03-24.
  5. ^ a b Blas E, Kurup AS, eds. (2010). Equity, social determinants and public health programmes. World Health Organization. pp. 182–183. ISBN 9789241563970.
  6. ^ a b Chaudhuri SK (2007). Practice Of Fertility Control: A Comprehensive Manual (7th ed.). India: Elsevier. p. 259. ISBN 9788131211502.
  7. ^ a b Rosenthal E (October 2007). "Legal or Not, Abortion Rates Compare". New York Times. Retrieved 2009-06-30.
  8. ^ a b Haddad LB, Nour NM (2009). "Unsafe abortion: unnecessary maternal mortality". Reviews in Obstetrics & Gynecology. 2 (2): 122–126. PMC 2709326. PMID 19609407.
  9. ^ a b Ganatra B, Gerdts C, Rossier C, Johnson BR, Tunçalp Ö, Assifi A, et al. (November 2017). "Global, regional, and subregional classification of abortions by safety, 2010-14: estimates from a Bayesian hierarchical model". Lancet. 390 (10110): 2372–2381. doi:10.1016/S0140-6736(17)31794-4. PMC 5711001. PMID 28964589.
  10. ^ "Unsafe abortion Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008". World Health Organization 2011. p. 2. It was estimated that in 2003 approximately 42 million pregnancies were voluntarily terminated: 22 million safely and 20 million unsafely.
  11. ^ a b "Induced Abortion Worldwide". Guttmacher Institute. 2016-05-10. Retrieved 2018-03-08.
  12. ^ Nour NM (2008). "An introduction to maternal mortality". Reviews in Obstetrics & Gynecology. 1 (2): 77–81. PMC 2505173. PMID 18769668.
  13. ^ Grimes DA (2003-12-01). "Unsafe abortion: the silent scourge". British Medical Bulletin. 67 (1): 99–113. doi:10.1093/bmb/ldg002. PMID 14711757.
  14. ^ a b Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, Shah IH (November 2006). "Unsafe abortion: the preventable pandemic". Lancet. 368 (9550): 1908–1919. doi:10.1016/S0140-6736(06)69481-6. PMID 17126724. S2CID 6188636.
  15. ^ Nations MK, Misago C, Fonseca W, Correia LL, Campbell OM (June 1997). "Women's hidden transcripts about abortion in Brazil". Social Science & Medicine. 44 (12): 1833–1845. doi:10.1016/s0277-9536(96)00293-6. PMID 9194245.
  16. ^ a b "Preventing unsafe abortion". WHO. Retrieved 2014-03-28.
  17. ^ "New findings from the WHO Multicountry Survey on Maternal and Newborn Health". WHO. Archived from the original on June 17, 2009. Retrieved 2014-03-28.
  18. ^ Sedgh G, Henshaw S, Singh S, Ahman E, Shah IH (October 2007). "Induced abortion: estimated rates and trends worldwide". Lancet. 370 (9595): 1338–1345. CiteSeerX 10.1.1.454.4197. doi:10.1016/S0140-6736(07)61575-X. PMID 17933648. S2CID 28458527.
  19. ^ Berer, Marge (June 2017). "Abortion Law and Policy Around the World". Health and Human Rights. 19 (1): 13–27. ISSN 1079-0969. PMC 5473035. PMID 28630538.
  20. ^ Welch A (27 September 2017). "Report finds nearly half of all abortions worldwide are unsafe". CBS News. Retrieved 5 December 2017.
  21. ^ Faúndes A, Barzelatto J (2006). The Human Drama of Abortion: a Global Search for Consensus. Vanderbilt University Press. p. 21. ISBN 9780826515261.
  22. ^ "Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003" (PDF). World Health Organization. 2007. Retrieved March 7, 2011. In several countries, the legalization of abortion has not been followed by elimination of unsafe abortion.
  23. ^ Safe Abortion: Technical and Policy Guidance for Health Systems. World Health Organization. 2003. p. 15. ISBN 9789241590341.
  24. ^ "Abortion Distortions: Senators from both sides make false claims about Roe v. Wade". August 22, 2005. Archived from the original on July 26, 2011. Retrieved February 20, 2021.
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  26. ^ Wilson J (January 22, 2013). "Before and after Roe v. Wade". CNN. Retrieved December 7, 2017.
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  29. ^ Gold RB (22 September 2004). "Lessons from Before Roe: Will Past be Prologue?". Guttmacher Institute.
  30. ^ Cardenas E, George H (5 January 2005). "Boy Faces Felony in Baseball Bat Abortion". Detroit News.
  31. ^ White P (January 13–21, 2005). "Baseball Bat Abortion". Boulder Weekly. Retrieved 2009-05-31.
  32. ^ "Michigan: Restrictions on Young Women's Access to Abortion". NARAL Pro-Choice America. Archived from the original on January 30, 2006. Retrieved 2009-05-31.
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  36. ^ Soubiran A (1969). Diary of a Woman in White (English ed.). Avon Books. pp. 98–99. citing Modnor H (1935). Fatal Abortions.
  37. ^ Avery M (1939). "My Family Speaks". Confessions of an Abortionist: Intimate Sidelights on the Secret Human, Sorrow, Drama and Tragedy in the Experience of a Doctor Whose Profession it is to Perform Illegal Operations (First ed.). Haldeman-Julius Company.. Accessed 14 December 2012.
  38. ^ Walker A (April 7, 2008). "Saving Nigerians from risky abortions". BBC News. Retrieved February 20, 2021.
  39. ^ "Uterine stimulants". Encyclopedia of Surgery. Retrieved February 20, 2021.
  40. ^ Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. (June 2014). "Global causes of maternal death: a WHO systematic analysis". The Lancet. Global Health. 2 (6): e323–e333. doi:10.1016/S2214-109X(14)70227-X. hdl:1854/LU-5796925. PMID 25103301.
  41. ^ a b Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, Shah IH (November 2006). "Unsafe abortion: the preventable pandemic". Lancet. 368 (9550): 1908–1919. doi:10.1016/S0140-6736(06)69481-6. PMID 17126724. S2CID 6188636.
  42. ^ Berer M (November 2004). "National laws and unsafe abortion: the parameters of change". Reproductive Health Matters. 12 (24 Suppl): 1–8. doi:10.1016/S0968-8080(04)24024-1. PMID 15938152. S2CID 33795725.
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  44. ^ Jewkes R, Rees H, Dickson K, Brown H, Levin J (March 2005). "The impact of age on the epidemiology of incomplete abortions in South Africa after legislative change". BJOG. 112 (3): 355–359. doi:10.1111/j.1471-0528.2004.00422.x. PMID 15713153. S2CID 41663939.
  45. ^ Bateman C (December 2007). "Maternal mortalities 90% down as legal TOPs more than triple". South African Medical Journal = Suid-Afrikaanse Tydskrif vir Geneeskunde. 97 (12): 1238–1242. PMID 18264602.
  46. ^ a b "Preventing unsafe abortion". World Health Organization. Retrieved 7 December 2017.
  47. ^ Vlassoff M, Shearer J, Walker D, Lucas H (December 2008). Economic impact of unsafe abortion-related morbidity and mortality: evidence and estimation challenges (PDF). Research Report. Vol. 59. Brighton, UK: Institute of Development Studies.
  48. ^ a b Ingelse C (January 2001). "The Committee Against Torture.". The UN Committee against Torture. Brill Nijhoff. pp. 89–123. doi:10.1163/9789004478114_007. ISBN 9789004478114. S2CID 239991865.
  49. ^ Adler AJ, Filippi V, Thomas SL, Ronsmans C (September 2012). "Quantifying the global burden of morbidity due to unsafe abortion: magnitude in hospital-based studies and methodological issues". International Journal of Gynaecology and Obstetrics. 118 (Suppl 2): S65–S77. doi:10.1016/S0020-7292(12)60003-4. PMID 22920625. S2CID 43126015.
  50. ^ Vlassoff M, Singh S, Onda T (October 2016). "The cost of post-abortion care in developing countries: a comparative analysis of four studies". Health Policy and Planning. 31 (8): 1020–1030. doi:10.1093/heapol/czw032. PMC 5013781. PMID 27045001.
  51. ^ Atuhaire S (October 2019). "Abortion among adolescents in Africa: A review of practices, consequences, and control strategies" (PDF). The International Journal of Health Planning and Management. 34 (4): e1378–e1386. doi:10.1002/hpm.2842. PMID 31290183. S2CID 195871358. Archived from the original (PDF) on 2022-05-30.
  52. ^ Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, Shah IH (November 2006). "Unsafe abortion: the preventable pandemic". Lancet. Sexual and Reproductive Health 4. 368 (9550): 1908–1919. doi:10.1016/S0140-6736(06)69481-6. PMID 17126724. S2CID 6188636.
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