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 most of these countries, abortion is illegal under nearly all circumstances, and the majority of procedures are unsafe. Even in countries where abortion is not severely restricted, women's access to safe procedures may be limited by lack of trained providers or other factors. Given these circumstances, women who undergo unsafe abortions are at high risk of complications, which when severe or when not treated may lead to death. Complications may be reduced by 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 the forthcoming 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.

Here's what you can find in the September special issue of International Perspectives on Sexual and Reproductive Health:

Unsafe abortion in Bangladesh widespread despite the availability of menstrual regulation services

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. In 2010, 647,000 induced abortions were performed in the country, and 231,400 women were treated for complications of such abortions, according to "The Incidence of Menstrual Regulation Procedures and Abortion in Bangladesh, 2010," by Susheela Singh, of the Guttmacher Institute, and colleagues. The authors, who analyzed data from a nationally representative sample of health facilities and knowledgeable key informants as well as MR statistics of nongovernmental organizations, found that 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, respectively). 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 MR, while the relatively high rate of complications suggests that the quality of MR services needs improvement.

In India, new study finds medication abortions provided by physicians are no more safe or effective than those provided by other trained health workers

Abortion is legal in India, but because of the limited number of trained surgical providers, a large proportion of abortions are unsafe, according to "Feasibility of Expanding the Medication Abortion Provider Base in India to Include Ayurvedic Physicians and Nurses." Shireen Jejeebhoy, of the Population Council, and colleagues explore the feasibility of expanding the medication abortion provider base to include nurses and traditional ayurvedic physicians, which would require amending existing laws. Currently only gynecologists and allopathic physicians who have undergone training and are certified to provide abortion are allowed to do so. 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, two poor Indian states in which access to health services is limited. 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 fewer than 5% of cases. Failure rates were low, and were statistically equivalent across provider types. No serious complications occurred, and the authors found that rates of patient satisfaction and willingness to have an abortion performed by a nurse or ayurvedic physician were very high. According to the authors, their findings support amending existing laws to allow nurses and ayurvedic physicians to provide medication abortion.

Study documents attitudes and beliefs toward abortion among South African medical students

In South Africa, although large majorities of medical students hold attitudes supportive of women's right to abortion services, three in four said say they do not intend to perform abortions once they are qualified to do so, according to "Attitudes and Intentions Regarding Abortion Provision Among Medical School Students in South Africa," by Stephanie Wheeler, of the University of North Carolina at Chapel Hill, and colleagues. Abortion is legal under South African law, yet access is limited by an 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 number of trained providers. The authors surveyed medical students at the University of Cape Town and Walter Sisulu University on their attitudes toward and intentions to provide abortions and found that nearly two-thirds of first-year students said they did not intend to perform abortions once they were qualified to do so. However, this proportion was only 45–60% among 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.

New evidence shows that most abortions in developed countries occur among women in their 20s

In developed countries, abortion is more common among women in their 20s than among women of other ages, according to "Legal Abortion Levels and Trends by Woman's Age at Termination," by Gilda Sedgh et al. of the Guttmacher Institute. In most industrialized nations, young adulthood is the period when women are most at risk of unintended pregnancy and its consequences. An increasing number of women want to postpone childbearing to pursue an education or work opportunities. To reduce the health toll of abortion complications—and decrease the incidence of abortion—it is vital to help women avoid unwanted pregnancies. Using data from more than 40 countries where legal abortion is generally available, the authors calculated age-specific abortion rates and percentage distributions of abortions by age, taking into account the estimated completeness of reporting. Drawing on information on contraceptive use and unmet need in the countries studied, the authors speculate that higher abortion rates in particular age-groups 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.

Also in this issue is a comment entitled "Use of Medicines Changing the Face of Abortion," by Beverly Winikoff and Wendy Sheldon of Gynuity Health Projects.