About 44 million abortions were performed worldwide in 2008, the most recent year for which data are available; more than four in five took place in developing countries. In many of these countries, abortions are illegal under most circumstances, and the majority are unsafe. Even in some countries where abortion is legal or not severely restricted, women’s access to safe procedures is limited by lack of trained providers or other factors. Given these circumstances, reducing abortion complications may require using techniques that allow earlier abortions, training midlevel health workers to provide abortions, educating medical students in abortion techniques and creating interventions to reduce unintended pregnancies. The articles in this special issue of International Perspectives on Sexual and Reproductive Health focus on providing evidence on ways to reduce the overall incidence of abortion and the health toll of unsafe abortions.
In Bangladesh, abortion is illegal except to save the woman’s life, but menstrual regulation (MR) can legally be performed up to a maximum of 10 weeks from the last menstrual period. Susheela Singh and colleagues estimate that, in 2010, 647,000 induced abortions were performed in the country, and 231,400 women were treated for complications of such abortions [page 122]. In addition, an estimated 653,000 MRs were performed, and about one in 10 women who had an MR were treated for complications. The annual rates of abortion and MR were similar (18.2 and 18.3 per 1,000 women aged 15–44). The similarity of these rates—and the fact that an estimated 26% of women seeking MRs were turned away, lead the authors to suggest that there is considerable unmet need for the latter service, while the relatively high rate of MR complications suggests that the quality of MR services needs improvement.
Abortion is legal in India, but because of the limited number of trained surgical providers, a large proportion of abortions are unsafe. Shireen Jejeebhoy and colleagues explore the feasibility of expanding the medication abortion provider base to include nurses and ayurvedic physicians, which would require amending existing laws [page 133]. Allopathic physicians, nurses and ayurvedic physicians (10 each), none of whom had experience in abortion provision, were trained and then provided medication abortions to a total of 1,225 women at five clinics in Bihar and Jharkhand. Their assessments of women’s eligibility for medication abortion on the basis of gestational age and of abortion completeness varied from those of an experienced physician “verifier” in only a small proportion of cases. Failure rates were low, and were statistically equivalent across provider types. No serious complications occurred, and women found services by all provider types acceptable. According to the authors, their findings support amending existing laws to allow nurses and ayurvedic physicians to provide medication abortion.
In South Africa as in India, abortion is legal, and access is limited by the inadequate number of trained providers; despite the increased use of medication abortion and the shifting of some first-trimester abortions from doctors in hospitals to midlevel clinicians at community health centers, the demand for services remains higher than the supply. Stephanie Wheeler and colleagues surveyed medical students at the University of Cape Town and Walter Sisulu University on their attitudes toward and intentions to provide abortions [page 154]. Although large majorities of students believed that women have the right to choose abortion and that conscientiously objecting clinicians should be required to refer women for abortion services, three in four said they did not intend to perform abortions once they were qualified to do so. However, this intention was expressed by two-thirds of first-year students, but only 45–60% of more advanced students; even larger differences across years of study were observed in the proportions who said they would try to discourage a patient from having an abortion or other health providers from performing abortions. The authors suggest that exposure to reproductive health content in the later years of the curriculum may account for these differences.
To reduce the health toll of abortion complications—and decrease the incidence of abortion—it is vital to help women avoid unwanted pregnancies. Designing interventions to accomplish this requires information that sheds light on the subgroups of women most likely to have an unintended pregnancy, which is generally available only in countries in which abortion is legal or not highly restricted. The type of information available in the data collection systems of these countries varies, but age is the most commonly recorded characteristic. Using data from more than 40 countries where legal abortion is generally available, Gilda Sedgh and colleagues calculated age-specific abortion rates and percentage distributions of abortions by age, taking into account the estimated completeness of reporting [page 143]. Drawing on information on contraceptive use and unmet need in the countries studied, the authors speculate that higher abortion rates in particular age-groups probably reflect higher than average levels of unmet need for contraception or difficulty in using methods effectively, as well as a stronger desire to avoid childbearing.
Since the advent of medication abortion in the late 1980s, increasingly more women in settings where abortion is illegal or highly restricted have, for the first time, had access to a safe, effective and discreet means of pregnancy termination. Although use of mifepristone, followed by a prostaglandin (usually misoprostol), is the regimen with the highest efficacy and the fewest side effects, misoprostol is often used alone when mifepristone is not available. Because it is inexpensive and stable at room temperature, it is ideal for use in low-resource settings. Noting that medication abortion is now an indispensable part of abortion care in developed countries, authors Beverly Winikoff and Wendy Sheldon call for equitable access for women in developing countries [page 164].