Safe and accessible: strategizing the future
HEIDI BART JOHNSTON
DEATH from unsafe abortion is the easiest and least expensive to prevent of the five leading causes of maternal mortality. Yet globally an estimated 67,000 women each year die as a result of complications of unsafe abortion. Tens of thousands more suffer serious injuries, including infection, haemorrhage, cervical laceration and uterine perforation (World Health Organization 2003). Unsafe abortion and related deaths and morbidity occur despite international agreements stating that where abortion is legal, it should be safe and accessible, and legislation in almost every country globally permitting abortion for some indication.
This paper reviews political, legal and medical aspects of the abortion issue, and provides programmatic examples and recommendations for preventing the unnecessary and tragic loss of lives and health as a result of unsafe abortion. It is critical for governments worldwide to acknowledge and fulfil obligations to reduce abortion related morbidity and mortality, particularly in the face of conservative movements working to reverse recent achievements in reproductive health policy and abortion-related care.
Early induced abortion is simple and ‘one of the safest medical procedures when performed by trained health care providers with proper equipment, correct technique, and applying universal precautions for infection control’ (WHO 2003). Where safe abortion services are accessible, the risk of death from unsafe abortion is less than one per 100,000 procedures (Alan Guttmacher Institute 1999).
Nonetheless, an estimated 19 million unsafe abortions occur globally, annually – the vast majority in developing countries. According to recent estimates, the highest rate of unsafe abortion is in Latin America, where an estimated 3.7 million take place annually, averaging 26 per 1000 women of reproductive age. In Africa, an estimated 4.2 million unsafe abortions are performed annually, averaging 22 per 1000 women. With the largest population of any region, Asia has the highest absolute number of unsafe abortions – about 10.5 million each year – although the estimated rate of unsafe abortion is the lowest in the developing world, at 11 per 1000 women. In Western Europe and North America the number of unsafe abortion is negligible (Ahman and Shah 2002).
Governments that are party to the declarations of the International Conference on Population and Development (United Nations 1994), the five-year review of the International Conference on Population and Development (United Nations 1999), the Fourth World Conference on Women (United Nations 1995) and the Convention on the Elimination of all Forms of Discrimination Against Women (United Nations 1979) have agreed that all individuals have the right to determine when and whether to have children, to abolish policies and practices that discriminate against women solely on the basis of their sex, and to make abortion safe and accessible in circumstances in which it is not against the law.
The 1999 ICPD+5 Programme Review Paragraph 63.iii underscores the obligation of governments to make safe abortion services available: ‘In circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible.’
Furthermore, the United Nations’ Millennium Development Goal calling for reductions in maternal mortality by 75% between 1990 and 2015 is unlikely to be met without adoption of strategies for reducing maternal deaths from abortion complications.
In addition to international conventions and agreements between governments, international professional organizations recognize their roles in decreasing abortion-related morbidity and mortality. The International Federation of Obstetrics and Gynaecology (FIGO) states that women have the right to medical or surgical abortion, and the health care service is obliged to provide that service as safely as possible (International Federation of Obstetrics and Gynaecology 1999). The International Confederation of Midwives (ICM) upholds that a midwife be prepared to appropriately treat, refer, and counsel women who have had induced or spontaneous abortions (International Confederation of Midwives 1996).
Progress toward international commitments to reduce maternal death and disability has been hampered by policies and funding restrictions of the United States’ Bush administration. The Mexico City policy, or ‘Global Gag Rule’ reinstated by Bush as one of his first acts in office, prohibits any organization receiving population funds from the U.S. Agency for International Development from using those or other, private funds, to provide abortions, inform their patients about abortion, or advocate for change in their nations’ abortion laws. The withholding of U.S. funds for international organizations including UNFPA and Marie Stopes, International stigmatizes efforts to address morbidity and mortality related to unsafe abortion.1 Such attempts to reverse recent gains in reproductive health policy should be seen as a call to action for continued progress toward the internationally agreed upon goals of reducing deaths and injury from unsafe abortion.
Strategies to reduce death and disability from unsafe abortion include amending and implementing abortion and related reproductive health policy, preparing health systems to meet the demand for abortion care services, and anticipating and providing care that meets the needs of special populations. Accessible safe abortion care has the advantages of saving women’s lives, preserving women’s health, and reducing the sometimes enormous health system expenditures for the treatment of women suffering complications from unsafe abortion (Figa-Talamanca, Sinnathuray et al. 1986, Johnson, Benson et al. 1993, WHO 2003).
Policy-related strategies to provide abortion services to the full extent of the law are crucial. Abortion is legal for some indication in virtually all countries globally. Over 60% of countries permit abortion to preserve the physical and mental health of the woman, nearly 40% of countries permit abortion in cases of rape or incest or foetal impairment, more than 30% of countries permit abortion on economic or social grounds, and at least 25% of all countries allow abortion on request (UN Population Division 1999). Thus virtually all countries should have accessible and safe services in place to provide abortion as permitted by law (WHO 2003).
Despite the widespread legality of abortion, in many countries safe services for legal indications are not accessible. In Brazil and Mexico, for example, abortion is a woman’s right when the pregnancy is the result of rape, but abortion services for this indication have been unavailable. To address this policy-practice gap, governments in both countries have worked with health care providers and women’s health and rights organizations to train and equip providers to offer comprehensive health services, including abortion, for rape survivors (Billings, Moreno et al. 2002, Faundes, Leocadio et al. 2002).
The policy strategy of training reproductive health care providers to be conversant with national laws and regulations as well as with technical procedures used to terminate pregnancies is critical to efforts to making abortion safe and accessible to the full extent of the law. As an example, in Vietnam a partnership of health care providers, ministry of health officials, and a women’s health organization has developed national abortion standards and guidelines, protocol and curricula, and established two regional abortion training sites. The partnership continues to work together to implement the standards and guidelines to improve the quality and accessibility of abortion care at all levels of the health care system (Ipas and IHCAR 2002).
Furthermore, many women are not aware of their right to legal abortion in certain circumstances or of the availability of safe, legal services. Essential policy-related advocacy includes effectively sharing information about legal indications for abortion needs with women of reproductive age.
Health system strategies can be drawn upon where abortion services are legally available but other barriers prevent women from accessing safe legal services. Common barriers include the lack of an abortion care service delivery model in place in the health care system, geographic distance to abortion care services, costs associated with abortion care, unnecessary administrative requirements, and provider or facility refusal to provide abortion-related services.
Abortion care service delivery includes multiple essential elements identified in the Postabortion Care (PAC) model for treatment of complications of unsafe abortion, and Comprehensive Abortion Care (CAC) model for elective abortion care. While the PAC model has been developed and adapted for over a decade, the CAC model is still being developed and tested. The essential elements of the PAC model for treating complications of unsafe abortion, include community and service provider partnerships, abortion and reproductive health counselling, treatment for complications of unsafe abortion, family planning and contraceptive services, and reproductive and other health services (Corbett and Turner 2003).
The essential elements included in the CAC model are pre-abortion counselling and physical assessment, including confirming and assessing the duration of the pregnancy; contraceptive counselling and referral; uterine evacuation, including appropriate infection prevention and pain management; monitoring and management of abortion-related complications; and recovery and follow-up care (McInerney, Baird et al. 2001, Baird and Flinn 2002, Ipas 2003).
Multiple assessments of the PAC service delivery model have shown that implementing postabortion care in a systematic way can increase postabortion contraceptive acceptance and can reduce costs to health care systems when vacuum aspiration is used and services are reorganized to ambulatory care settings (Johnson, Benson et al. 1993, Benson, Huapaya et al. 1998, Nawar, Huntington et al. 1999). Systematically linking contraceptive counselling and service delivery with abortion care has been found vital to ensuring that patients who desire to prevent or delay subsequent pregnancies leave the service delivery site with a contraceptive method, or information about how to obtain the method (Farfan, Kestler et al. 1997, Benson, Huapaya et al. 1998, Thang, Johnson et al. 1998, Diaz, Loayza et al. 1999, Langer, Garcia-Barrios et al. 1999, Solo, Billings et al. 1999, Billings, del Pozo et al. 2001, Johnson, Ndhlovu et al. 2002).
Geographic accessibility to safe, legal abortion services for all eligible women requires the decentralization of services. Strategies for decentralization include engaging midlevel health professionals in abortion care service delivery, developing working referral networks, and using technology appropriate for low resource settings.
Anumber of countries including Bangladesh, Cambodia, South Africa, Mozambique, Sweden and the United States, have adopted the strategy of trained health care professionals such as nurses, midwives, clinical officers, physician assistants, and others providing menstrual regulation or abortion-related care (Billings, Ankrah et al. 1999, Dickson-Tetteh and Billings 2002, Population Council 2000, Yumkella and Githiori 2000, University of North Carolina 2001, Ipas and IHCAR 2002, WHO 2003). These midlevel health care providers tend to be more numerous and more geographically dispersed than physicians. Given appropriate training, they are well qualified to offer abortion-related care, particularly at the primary care level (Ipas and IHCAR 2002). A comparative study conducted in the United States has shown no difference in complication rates between women who had first trimester abortions using manual vacuum aspiration performed by a physician assistant and those who had the same procedure performed by a physician (Freedman, Jillson et al. 1986).
A well-functioning referral system is critical to making safe abortion care accessible. Community outreach, health centre, clinic, and hospital staff should be able to direct women to appropriate services. To ensure that women who need care for complications of unsafe abortion receive prompt treatment, referral and transport arrangements between all levels of the health care system are necessary (WHO 2003). In Kenya, a national postabortion care initiative is working to ensure that women in rural communities with postabortion complications receive timely and appropriate care by linking community level health care providers such as community health workers and contraceptive distributors to the formal referral system and training midwives in postabortion care. At least one training site reports a dramatic decline in hospital admissions for abortion complications (Oguttu and Odongo 2001).
Technology for safe abortion is appropriate for decentralized settings. The principal clinical competency required to perform abortion care is the removal of products of conception from the uterus. For low resource settings manual vacuum aspiration, which employs a portable, nonelectric, handheld vacuum aspirator, is appropriate (Salter, Johnston et al. 1997, Ipas and IHCAR 2002, Iyengar and Iyengar 2002, WHO 2003). Medical methods of abortion also have been proved safe, effective, and acceptable in low-resource settings including in China, Cuba, India, Tunisia, and Vietnam (Elul, Ellertson et al. 1999, Ngoc, Winikoff et al. 1999, Elul, Hajri et al. 2001, WHO 2003).
To be able to maintain high quality care, the decentralization of services necessary to grant women geographical access to safe abortion care requires strong logistical and personnel support.
Specific populations, including women with minimal access to financial resources, adolescents, refugees and displaced women, and women infected with HIV have particular needs related to abortion care that health systems must anticipate and attempt to meet.
Financial accessibility to abortion care is as important as geographic accessibility. Health system charges, additional ‘informal charges’ made by providers, and travel costs can render services inaccessible to women with minimal access to financial resources. Where safe services are dauntingly expensive, women are more likely to delay seeking care for complications of unsafe abortion, or seek care from unsafe providers and require hospitalization for serious complications (Johnston, Ved et al. 2003) and thus cost the health system more in the long run. The World Health Organization recommends that ‘abortion never be denied or delayed because of a woman’s inability to pay’ (WHO 2003).
Youth aged 15-24 currently number 1.1 billion globally, and this population continues to grow. Youth suffer disproportionately from unsafe abortion. Over 4.4 million women aged 15-19 have abortions every year, 40% of which are performed under unsafe conditions (UNFPA 2003). The incidence of unsafe abortion is rising among unmarried adolescents, especially where abortion is legally restricted and fertility-regulation services are inaccessible to young people. Young people need, want and have a right to reproductive and sexual health services. Ignoring their sexuality leaves them vulnerable to unwanted pregnancy, unsafe abortion, and sexually transmitted diseases, including HIV/AIDS.
Affordable, accessible, and confidential youth-friendly reproductive and sexual health services are essential to decreasing levels of unsafe abortion among youth. A study comparing teenage sexual and reproductive behaviour in Sweden, France, Canada, Great Britain, and the United States found that ‘where young people receive social support, full information, and positive messages about sexuality and sexual relationships, and have easy access to sexual and reproductive health services, they achieve healthier outcomes and lower rates of pregnancy, birth, abortion, and sexually transmitted diseases’ (Alan Guttmacher Institute 2001).
Refugee women are at relatively high risk of forced and unprotected sex, and thus of unwanted pregnancy and unsafe abortion. The need for safe abortion services for refugee and displaced women is acute: according to UNFPA, 25-50% of maternal deaths in refugee settings result from complications of unsafe abortion (UNFPA 1999, Lehmann 2002). Refugee women have the right to information on legal indications for abortion, and to safe, accessible, and confidential abortion care, including care for complications of unsafe abortion, and contraceptive services. These needs are too often ignored.
Women with unwanted pregnancy, particularly young women, are at risk of sexually transmitted infections including HIV. Eleven population-based studies fielded in several African nations demonstrated that average infection rates were over five times higher for teenage girls than teenage boys (UNAIDS 2000). Young women are particularly vulnerable due to a combination of their immature genital tracts, older male sexual partners, prevalence of sexual violence, and low social status – among other factors (UNAIDS 2000). This underscores the importance of including information about safe abortion care in HIV/AIDS prevention and treatment programmes, and offering STI and HIV/AIDS counselling and testing when providing abortion care services.
Women with minimal access to financial resources, adolescents, refugees and displaced women, women infected with HIV, and other population subgroups clearly have special sexual and reproductive health care needs. However in most cases there are more questions than answers regarding how to effectively meet these needs, particularly when it comes to safe abortion care.
While a conservative movement threatens to weaken women’s reproductive rights internationally, simultaneously the global community has never before been so united in the call to reduce morbidity and mortality from unsafe abortion. Governments have agreed to make abortion safe and accessible in circumstances in which it is not against the law. Simple, affordable technologies for abortion and postabortion care are available. While a great deal needs to be done in terms of developing, implementing, and documenting interventions, measuring impact, and disseminating successful strategies, the basic approaches for decentralizing services and meeting the needs of population subgroups are acknowledged.
To reduce the unnecessary morbidity and mortality from unsafe abortion, research, policy, advocacy, and service delivery work needs to continue to expand on international, national and local levels. Without this continued progress, women will continue unnecessarily to die and suffer serious morbidity from preventable and treatable complications of unsafe abortion.
* Please address questions and comments to Heidi Bart Johnston, (email@example.com). Ipas is a nonprofit organization that focuses on abortion care issues worldwide, and manufactures and sells manual vacuum aspiration (MVA) equipment.
1. In 2002 and 2003 U.S. funds for UNFPA and Marie Stopes, International were withdrawn because the U.S. administration claims that both organizations support forced abortions in China. However, a team from the U.S. government investigated the claim in China and found no supporting evidence.
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