Bankole (Guttmacher) - Unsafe Abortion


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  • Unsafe abortion has a significant negative impact on women’s health and survival, particularly in the developing world. Most of us do not have to be convinced of that fact. Particularly those of us who have lived and worked in developing countries. What we are still trying hard to do is to document more accurately the nature and extent of this impact. This has not proven to be an easy task given that abortion is both legally restricted and highly stigmatized in most of the developing world. Unsafe abortion is highly common in environments where the procedure is highly restricted and stigmatized. Yet, thanks to the unrelenting efforts of some organizations and individuals, we now have fairly reasonable knowledge of not only the incidence of unsafe abortion but also its determinants and consequences. With this information we are in a better position today to help decision makers to find solutions. This presentation provides some key findings in the literature on unsafe abortion and its consequences.
  • Bankole (Guttmacher) - Unsafe Abortion

    1. 1. An Overview of Abortion Worldwide Akinrinola Bankole, Ph.D. Director of International Research Presentation given at NYU, 9/9/08
    2. 2. Overview <ul><li>Definition and types of abortion </li></ul><ul><li>Legal Status and Incidence of Abortion </li></ul><ul><li>Measurement of Abortion </li></ul><ul><li>Conditions Under Which Women Have Abortion </li></ul><ul><li>Impact of Unsafe Abortion on Maternal Morbidity And Mortality </li></ul><ul><li>The Root Cause of Abortion </li></ul>
    3. 3. Definition
    4. 4. Abortion <ul><li>The termination of a pregnancy at any time after implantation in the uterus and before viability (ability to survive outside the uterus). </li></ul><ul><li>It may be either spontaneous (miscarriage) or induced (terminated on purpose). </li></ul>
    5. 5. Unsafe and Safe Abortion <ul><li>WHO defines unsafe abortion as a procedure for terminating an unplanned pregnancy carried out either by: </li></ul><ul><li>(a) persons lacking the necessary skills or </li></ul><ul><li>(b) in an environment that does not conform to minimal medical standards, or </li></ul><ul><li>(c) both </li></ul><ul><li>Any abortion that does not occur under any the above conditions is considered a safe abortion </li></ul>
    6. 6. Legal and Illegal Abortion <ul><li>A legal abortion is an induced abortion that meets the legal requirements of the country in which it takes place </li></ul><ul><li>Otherwise, it is an illegal abortion in the context of that country </li></ul><ul><li>The legality and safety of abortion are closely related but not synonymous: Generally, legal abortions are mostly safe and illegal abortions are mostly unsafe </li></ul>
    7. 7. Legal Status and Incidence of Abortion
    8. 8. 36% the world’s population live where abortion is very restricted Maximum Criteria* * Each includes more restrictive criteria Source: Center for Reproductive Rights, 2006
    9. 9. Most countries with legal abortion are in developed regions ██   Legal on request ██   Legal for health, mental health, socio-economic factors ██   Legal for health, mental health
    10. 10. Women are as likely to have abortions, whether the law is restrictive or not Abortion rates per 1000 women aged 15 – 44
    11. 11. Almost half of the 42 million abortions in 2003 are unsafe % of all abortions
    12. 12. Restricting contraception and legal abortion in Romania resulted in increased maternal and abortion-related deaths Contraception/ Abortion liberalized Contraception/Abortion restricted Source: UNDP, UNFPA, WHO, World Bank
    13. 13. In South Africa, legalization saved lives <ul><li>Between 1994-2000, severity of abortion related complications dropped: </li></ul><ul><ul><li>Fewer post-abortion infections </li></ul></ul><ul><ul><li>Larger gains by young women </li></ul></ul><ul><li>Deaths due to unsafe abortion declined by at least 50% </li></ul>Source: Jewkes et al., 2004
    14. 14. Measurement of Abortion
    15. 15. Legal abortions <ul><ul><li>- Sources of data: </li></ul></ul><ul><ul><ul><li>Government statistics </li></ul></ul></ul><ul><ul><ul><li>Census of abortion providers </li></ul></ul></ul><ul><ul><ul><li>Nationally representative surveys </li></ul></ul></ul><ul><ul><li>Estimation of incidence: </li></ul></ul><ul><ul><ul><li>Data from these sources are often regarded as largely complete. </li></ul></ul></ul><ul><ul><ul><li>Where there are reasons to believe that data are incomplete, opinions of experts may be used to adjust the estimate. </li></ul></ul></ul>
    16. 16. Illegal abortion <ul><li>Difficult to obtain high quality data because: </li></ul><ul><ul><li>Sensitivity of issue – social stigma, legal restrictions </li></ul></ul><ul><li>Official statistics often poor or non-existent </li></ul><ul><li>Women greatly underreport on surveys </li></ul><ul><li>Researchers have developed methodologies to compensate for these problems </li></ul>
    17. 17. Some methodologies for estimating incidence <ul><li>Cross-sectional Community Surveys (with interviewer or self administered questionnaire) </li></ul><ul><li>Random-Response Technique </li></ul><ul><li>Audio Computer-Assisted Self-Interview (ACASI) </li></ul><ul><li>Secret Ballot / Sealed Envelope Method </li></ul>
    18. 18. Some methodologies for estimating induced abortion (cont ’ d) <ul><li>Abortion/Health Providers Survey </li></ul><ul><li>The Anonymous Third Party Reporting Method (e.g. The Confidant Method) </li></ul><ul><li>Residual Method of Bongaarts ’ Proximate Determinants Method </li></ul><ul><li>Hospital Complications Method -Guttmacher </li></ul>
    19. 19. Hospital Complications method has been applied in: <ul><li>Brazil (1994) </li></ul><ul><li>Chile (1994) </li></ul><ul><li>Colombia (1994) </li></ul><ul><li>Dominican Republic (1994) </li></ul><ul><li>Mexico (1994) </li></ul><ul><li>Peru (1994 & 2000) </li></ul><ul><li>Bangladesh (1997) </li></ul><ul><li>Philippines (1997 and 2005) </li></ul><ul><li>Nigeria (1998) </li></ul><ul><li>Pakistan (2004) </li></ul><ul><li>Uganda (2005) </li></ul><ul><li>Guatemala (2006) </li></ul><ul><li>Mexico (2008) </li></ul><ul><li>Ethiopia and Burkina Faso (on going) </li></ul>
    20. 20. The Method ’ s Approach Number of Induced Abortions in a Country Abortions Treated in Hospital Abortions Not Reaching Hospital (safe and unsafe) Data: Num. women treated for hosp comp due to abort Source: Hospital Data Data: 1/ Prop. of women having an abort. who are hospitalized Source: Health Professional Survey
    21. 21. Number of women treated in hospitals for complications of induced abortion <ul><li>Data available varies by country </li></ul><ul><li>Good official data - Latin America </li></ul><ul><li>Hospital records available - Philippines </li></ul><ul><li>Hospital data and records not available or largely incomplete: therefore require: </li></ul><ul><ul><li>A Health Facility Survey – HFS - Uganda </li></ul></ul><ul><ul><li>And/or Ipas Magnitude Study - Ethiopia </li></ul></ul>
    22. 22. Calculation: Calculate number treated for induced and spontaneous abortion <ul><li>Count of women treated for PAC must be divided into induced and spontaneous abortion </li></ul><ul><li>Two steps needed to divide: </li></ul><ul><li>- Clinical studies of pattern of pregnancy loss used to estimate # late spontaneous (13-22 weeks) – assumed to need medical care in hospital/facility </li></ul><ul><li>- % late spontaneous abortion patients treated in hospital is estimated to be equal to % women who deliver in hospital </li></ul>
    23. 23. The Health Professional Survey: Proportion of women hospitalized <ul><li>Not all women who have abortions experience complications, or receive treatment: Some </li></ul><ul><ul><ul><li>-Have safe, uncomplicated abortions </li></ul></ul></ul><ul><ul><ul><li>-Experience complications, but receive no care </li></ul></ul></ul><ul><ul><ul><li>-Obtain care from private doctor </li></ul></ul></ul><ul><ul><ul><li>-Die before obtaining care </li></ul></ul></ul><ul><ul><li>To measure the proportion of women having an abortion who did not obtain care in hospital for whatever reason: Obtain through the “Health Professional Survey” </li></ul></ul>
    24. 24. HFS provides estimated number of women who obtain treatment in hospital/facility for complications. HPS provides estimate of multiplier = (1/[Proportion hospitalized among all women who obtain induced abortions): e.g. (1/.25) = multiplier of 4 Estimated total number of induced abortions = # treated in facilities * multiplier Estimate A Estimate B Directly measurable Steps in the calculation Some of these complications are due to induced abortions.
    25. 25. 110,000 women hospitalized for post-abortion complications in 2003 Some women experience no complications or do not obtain hospital treatment An estimated 300,000 induced abortions Subtract an estimated 25,000 miscarriages Multiply by 3.5 Findings: Example of Uganda 85,000 cases of complications were due to induced abortions
    26. 26. Conditions of Abortion Provision
    27. 27. Abortion Provision in Nigeria Most women obtain abortions in hospitals or clinics
    28. 28. Abortion Provision in the Philippines Most poor women obtain abortions from unsafe providers
    29. 29. Abortion Methods in Nigeria
    30. 30. Abortion Methods in the Philippines
    31. 31. Impact of Unsafe Abortion on Maternal Morbidity & Mortality
    32. 32. Health complications are common consequences of unsafe abortion <ul><li>About 1 in 5 with unsafe abortion need post abortion care but do not get it </li></ul><ul><li>Delay in obtaining care is common and leads to worse health outcomes </li></ul><ul><li>Large burden on the health-care system </li></ul><ul><li>Abortion in the second trimester greatly increases risk </li></ul><ul><li>There are many long-term consequences </li></ul>
    33. 33. Magnitude of Unsafe Abortion Complications treated in Hospitals Country, date Number of women Annual rate of complications per 1000 women Guatemala, 2003 21600 8.6 Nigeria, 1996 142,200 6.1 Pakistan, 2002 197,000 7.0 Peru, 1998 50,000 8.6 Philippines, 2000 78,150 4.4 Uganda, 2002 85,000 16.4
    34. 34. Abortion Complications in the Philippines
    35. 35. Abortion complications in Nigeria
    36. 36. Diagnosis of abortion complications Example of Nigeria
    37. 37. Deaths from unsafe abortion are highest in Africa Deaths per 100,000 unsafe abortions, 2003
    38. 38. Unintended Pregnancy, Contraception and Abortion Link
    39. 39. More than one-third of all pregnancies in developing countries each year are unintended, and 19% end in abortion pregnancies in developing countries (182 million)
    40. 40. Most unintended pregnancies occur among women who were not using any contraceptive Modern method No method Traditional method Unintended pregnancies in developing countries, by women’s contraceptive use
    41. 41. More than 100 million married women have an unmet need for contraception Guttmacher Institute Number (in millions) and % distribution of married women with unmet need 60 (56%) 29 (27%) 7 (7%) 9 (8%) 3 (3%)
    42. 42. Reasons for not using contraception compared: results for 55 countries % of married women 15-49 reporting each problem
    43. 43. The relative importance of some reasons has changed over time Guttmacher Institute % of married women 15-49 with unmet need 1986-1989 2002-2005
    44. 44. Abortion levels and trends are strongly linked to modern contraceptive use Index of changes in rates, Russian Federation
    45. 45. Conclusion <ul><li>That unsafe abortion merits the same scientific approach as other threats is evident from its consequences </li></ul><ul><li>To tackle this problem more effectively, there is need for more reliable evidence, particularly at country level </li></ul><ul><li>National governments and donors should invest more in making available compelling abortion statistics </li></ul><ul><li>Prevention of unintended pregnancy, availability of adequate post-abortion care and safe abortion are pertinent of program and policy priority. </li></ul>
    46. 46. For more information, visit