The World Health Organization estimates that every year, nearly 5.5 million African women have an unsafe abortion; 1.7 million of these women are hospitalized for treatment of abortion complications, and many more seek care from traditional healers or receive no care at all. As many as 36,000 die from complications of the procedure. The accuracy of estimates of unsafe abortion and its sequelae vary from country to country, depending on many factors, including the legal status of abortion.
Ethiopia is a case in point.Until recently, abortion was permitted only to save the life of the woman or preserve her health from grave danger. One in 27 women died from complications of pregnancy or childbirth, and 673 women died for every 100,000 live births. Yet in 2005, when the grounds for legal abortion were expanded, no estimates of the incidence of unsafe abortion existed, and the extent to which unsafe abortion contributed to these high levels of complications and mortality was unknown. Two related articles in this issue make a start at filling these gaps.
According to the lead article, by Hailemichael Gebreselassie and colleagues, almost 58,000 Ethiopian women sought care at a public or private medical facility for complications of induced or spontaneous abortion in 2008 [see article]. Some 41% had moderate or severe complications, such as signs of infection, that were likely related to an unsafe abortion, and 7% had signs of a mechanical injury or a foreign body inserted into the vagina. More than 13,000 of those seeking care required a hospital stay of at least 24 hours. The fatality rate at public hospitals, where themost seriously ill cases were treated, was 629 per 100,000 women with complications.
In the second, related article, Susheela Singh and colleagues used these estimates of abortion complications, along with other data, to calculate that 382,000 induced abortions were performed in Ethiopia in 2008, of which only about one-quarter (103,000) were legal [see article]. Nationally, the annual abortion rate was 23 per 1,000 women aged 15–44, but the rate variedwidely across the country: The rate in Addis Ababa (49 per 1,000)was twice the national level. Noting that the percentage of all pregnancies thatwere unintended in Addis Ababa (72%) was also much higher than the percentage nationwide (42%), the authors suggest that improving access to family planning services is critical to reducing morbidity and mortality from unsafe abortions.
In Central America, where levels of poverty are high and access to reproductive health care is poor, adolescent fertility is higher than the average in Latin America (104–137 vs. 75 births per 1,000 women aged 15–19). According to data from nationally representative health and demographic surveys conducted between 1987 and 2007 (four for each country), the risk that women aged 15–19 had had sex rose over the two decades in El Salvador, Honduras and Nicaragua, but remained stable in Guatemala [see article]. Meanwhile, the odds that adolescent women had entered their first union increased in El Salvador, declined in Nicaragua, but remained stable in the other two countries. Over time, adolescents in all four countries were increasingly likely to have used a modern contraceptive method; however, Nicaragua was the only country in which their odds of having given birth decreased. Noting that reproductive outcomes were generally better for young women with more years of schooling and higher socioeconomic status, authors Ghazaleh Samandari and Ilene Speizer recommend that programs focus on improving young people’s educational and economic opportunities.
Pregnancy ambivalence and its influence on contraceptive use have been studied amongwomen, but not as a couple issue.Usingmatched couple data from the Indonesia Demographic and Health Survey, Janine BardenO’Fallon and Ilene Speizer examined the influence of husbands’ fertility desires and attitudes toward pregnancy on couples’ contraceptive use [see article]. Among couples wanting to stop or delay childbearing, 64%of spouses using contraceptives and 61%of spouses not using contraceptives agreed on whether an unexpected pregnancy would be a problem. In the majority of discordant couples, the husband reported it would be no problem and the wife reported it would be a big or small problem. Since, according to multivariate analysis, the odds of contraceptive use were significantly lower among couples with discordant fertility desires, these findings suggest that husbands’ fertility desires are a major influence on contraceptive use.
Also in This Issue
Although all models of postabortion care include family planning counseling and provision as well as emergency treatment, those services have often been neglected in practice [see article]. In their Comment, Carolyn Curtis and colleagues cite numerous studies demonstrating the value of these services; the addition of family planning services to postabortion care has not only reduced repeat unintended pregnancy and abortion and their health consequences, but has also lowered costs to overburdened health facilities by preventing the need for repeat treatment.