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Unsafe abortion

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Soviet poster c. 1925. Title translation: "Abortion induced by either self-taught midwife or obstetrician not only maims the woman, but also often leads to death."

Unsafe abortions are defined as procedures for terminating a pregnancy that are “performed by persons lacking the necessary information or skills, in an environment lacking minimal medical standards, or both.”[1] These include self-induced abortions, abortions in unhygienic conditions, and abortions performed by medical practitioners who do not provide appropriate post-abortion attention.[2] About 45% of the 73 million abortions each year are considered unsafe, amounting to about 33 million unsafe abortions.[3]

Most (97%) unsafe abortions occur in the developing world,[4] where modern birth control is not readily available,[5] and affordable, well-trained medical practitioners are scarce,[6] and abortion is often illegal, with the more restrictive the law, the higher the rates of death and other complications.[7]

Unsafe abortions are one of the leading causes of death during pregnancy and childbirth, accounting for about 5–13% of deaths during this period.[8] This number is likely an underestimate given the stigma against and likely misclassification of unsafe abortion.[9] In the developing world alone, unsafe abortions result in complications for about 7 million women a year.[10]

Overview

[edit]

The World Health Organization (WHO) estimates that around 73 million induced abortions take place worldwide each year.[11] According to estimates from 2010 to 2014, approximately 45% of these abortions are unsafe.[12] Out of this 45%, about 30% of abortions were less safe (meaning that either 1) the abortion was performed by a trained provider but with an unsafe method or 2) a safe abortion method was used but without adequate information or support from a trained provider) and about 15% were least safe (meaning that abortion was done using an unsafe method AND without support from a trained provider).[13]

Unsafe abortion is a major cause of injury and death among women worldwide. According to WHO and the Guttmacher Institute, at least 22,800 women die annually as a result of complications of unsafe abortion;[14] according to Doctors Without Borders, this number is likely closer to 29,000 women.[15] Additionally, between 2 million and 7 million women each year survive unsafe abortion but sustain long-term damage or disease (incomplete abortion, infection, sepsis, bleeding, and injury to the internal organs, such as puncturing or tearing of the uterus).[16] A greater proportion of deaths occur in Latin America, the Caribbean, and sub-Saharan Africa, while a smaller proportion of deaths occur in East Asia (where access to abortion is generally legal).[17] These figures may not be completely accurate, as the incidence of unsafe abortions may be difficult to measure due to possible reporting as a miscarriage, “induced miscarriage,” “menstrual regulation,” “mini-abortion” and “regulation of a delayed/suspended menstruation.”[18]

The WHO and Guttmacher Institute also found that abortion is safer in countries where it is legal, but dangerous in countries where it is outlawed and performed in secret.[19] In developed countries, where abortion laws tend to be more liberal, nearly all abortions (92%) are safe. In contrast, in developing countries, where abortion laws tend to be more restrictive, only about 45% of abortions are safe.[20] Consequently, unsafe abortion-related deaths are more frequent in countries with more restrictive abortion laws (34 deaths per 100,000 births) than in countries with less restrictive laws (<1 death per 100,000 births).[21] Legalizing abortion may therefore play a major role in reducing the frequency of unsafe abortion; this is supported by a 2019 study that found that countries with more flexible abortion laws had lower rates of maternal mortality.[22] Still, the most repressive laws still apply to over 40% of the world population, and if found out, these women may face prosecution for an unsafe abortion, and later incarceration.[23]

Because of these findings, groups such as the World Health Organization have long advocated for a public-health approach to addressing unsafe abortion, emphasizing the legalization of abortion, the training of medical personnel, and ensuring access to reproductive-health services.[24]

WHO’s Global Strategy on Reproductive Health, adopted by the World Health Assembly in May 2004, noted: “As a preventable cause of maternal mortality and morbidity, unsafe abortion must be dealt with as part of the MDG on improving maternal health and other international development goals and targets.”[25] The WHO’s Development and Research Training in Human Reproduction (HRP), whose research concerns people’s sexual and reproductive health and lives, has an overall strategy to combat unsafe abortion that comprises four interrelated activities:[26]

Collate, synthesize, and generate scientifically sound evidence on unsafe abortion prevalence and practices

Develop improved technologies and implement interventions to make abortion safer

Translate evidence into norms, tools, and guidelines

Assist in the development of programmes and policies that reduce unsafe abortion and improve access to safe abortion and high-quality post-abortion care

A later article pre-printed by the WHO called safe, legal abortion a “fundamental right of women, irrespective of where they live” and unsafe abortion a “silent pandemic.” The article states “ending the silent pandemic of unsafe abortion is a public-health and human-rights imperative.” It also states “access to safe abortion improves women’s health, and vice versa, as documented in Romania during the regime of President Nicolae Ceaușescu” and “legalization of abortion on request is a necessary but insufficient step toward improving women’s health,” citing that in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers.[27]

Conflating illegal and unsafe abortion

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Unsafe abortions often occur where abortion is illegal, but it is important to recognize that unsafe abortions can also occur where abortion is legal, and that the existence of liberal abortion law does not eliminate unsafe self or home abortion as a preferred possibility. For example, in India and Cambodia, where abortion is legally available upon request (India’s Medical Termination of Pregnancy Act in 1971 and Cambodia’s National Abortion Law in 1997), women still attempt unsafe self-abortions before seeking professional healthcare – in 1996, the Socio-Economic Survey of Cambodia found that 35% of treatment was provided by a parent or relative, with this figure rising to 71% in remote provinces. Only 16% of treatment was provided by health center staff. The home was perceived as the safest place for health care.[28]

Uganda’s law explicitly allows safe and legal abortion under a variety of circumstances, as permitted by Article 224 of Uganda’s Penal Code and the 2006 National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights, but a 2016 Demographic Health Survey found that 16–18 women die every day due to pregnancy-related causes, 33% of which are due to unsafe abortion.[29]

Social stressors are also a major determinant of unsafe abortion rates, even in countries where abortion is legal. As of 2013 in Zambia, there is a high ratio of induced abortion mortality despite medical legality, and more than half of those deaths were of school girls. Many seek backdoor abortions for many reasons; some being a fear of being expelled from school or being socially ostracized.[30]

Similarly, safe abortions can occur where abortion is illegal, as women may be able to afford medically appropriate services despite illegality.

The prevalence of unsafe abortion can be determined by factors other than legality, such as access to safe and effective contraception and medical advances like penicillin.[31] It has been estimated that the incidence of unsafe abortion could be reduced by as much as 73% without any change in abortion laws if modern family planning and maternal health services were readily available globally.[32]

Frequency by continent

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Region Number of unsafe abortions (thousands) Number of unsafe abortions per 100 live births Number of unsafe abortions per 1000 women
Africa 4200 14 24
Asia* 10500 14 13
Europe 500 7 3
Latin America and the Caribbean 3700 32 29
North America Negligible incidence Negligible incidence Negligible incidence
Oceania ** 30 12 17
World 19000 14 14
* Excluding Japan
** Excluding Australia and New Zealand

Source: WHO 2006[33]

Abortion in the U.S. before 1973 (Roe v. Wade)

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Early abortion laws generally only prohibited the use of toxic chemicals in pursuit of a miscarriage. The first such law was passed in Connecticut in 1821.[34]

Later, in the 1940s, records show that more than 1,000 women died each year from abortions that were labeled as unsafe. Many of these abortions were self-induced. Unsafe abortions were such a concern in the United States that nearly every large hospital had some type of “septic abortion ward” that was responsible for dealing with the complications that accompanied an incomplete abortion. Incomplete abortions were the leading cause for OB-GYN services across the United States.[35]

In the 1960s, the National Opinion Research Center found that hundreds of women were attempting to self-abort with coat hangers, knitting needles, and ballpoint pens, and by swallowing toxic chemicals like bleach and laundry detergent.[36]

Prior to 1973, the authority to legalize abortion rested with state governments. Up through the 1960s, 44 states had laws that outlawed abortion unless the health of the pregnant patient was at stake.[37] The Centers for Disease Control and Prevention estimates that in 1972, 130,000 women attempted self-induced abortions or obtained illegal abortions, resulting in 39 deaths.[38]

In 1973, the Supreme Court ruled 7–2 that laws prohibiting an abortion violated a woman’s right to privacy. The landmark case, Roe v. Wade, changed abortion in the United States, reducing the number of deaths from unsafe abortions.[39]


[edit]

In 2005, the Detroit News reported that a 16-year-old boy, at his pregnant, under-age girlfriend's request, repeatedly beat her abdomen with a bat to abort the fetus. The young couple lived in Michigan and were evading a state law requiring a minor to receive a parent's or a judge's consent to obtain a legal abortion.[40][41][42] In Indiana, where there were also parental consent laws, 17-year-old Becky Bell died from an unsafe abortion in 1988 rather than discuss her pregnancy and wish for an abortion with her parents.[43][44] [better source needed]

International unsafe abortion cases

[edit]

In Pakistan, abortion is only legal for the purpose of saving the mother’s life, with no exceptions for rape, incest, fetal abnormalities, or elective reasons. As of 2013, 40% of abortions are performed by unskilled providers in unhygienic back street clinics. A 2013 study presented a case study of a 29 year old Pakistani woman who underwent an unsafe abortion due to unintended pregnancy, resulting in uterine perforation. After perforating her uterus, the unskilled provider pulled out her bowel through her vagina, causing loss of a major portion of her small intestine, resulting in short bowel syndrome.[45]

In Africa, almost 97% of abortions are unsafe. While abortion was illegal in Kenya in 2012, Akech Ayimba underwent an unsafe abortion where she was not given any anaesthetic, despite seeking out the procedure with a gynecologist at an abortion clinic.[46]

Methods

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Methods of unsafe abortion include:

Health risks

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Unsafe abortion is a major cause of injury and death among women worldwide. It is estimated that nearly 25 million unsafe abortions take place annually.[52] WHO estimates that at least 7.9% of maternal deaths are due to unsafe abortion, with a greater proportion occurring in Latin America, the Caribbean, and sub-Saharan Africa and a lesser proportion in East Asia where access to abortion is generally legal.[53] 97% of these abortions take place in developing countries.[54] Unsafe abortion is believed to result in at least 22,800 deaths and millions of injuries annually.[54] The legal status of abortion is believed to play a major role in the frequency of unsafe abortion.[55][56] For example, the 1996 legalization of abortion in South Africa had an immediate positive impact on the frequency of abortion-related complications,[57] with abortion-related deaths dropping by more than 90%.[58] Groups such as the World Health Organization have advocated a public-health approach to addressing unsafe abortion, emphasizing the legalization of abortion, the training of medical personnel, and ensuring access to reproductive-health services.[56]

An unsafe abortion can lead to wide range of health risks that can affect the well-being of women. Complications of unsafe abortion include severe hemorrhage, sepsis, perforation of the uterus or intestines, chronic pelvic pain, and infertility. Recent studies emphasize that timely post-abortion care significantly reduces fatal outcomes, yet access remains limited in many regions. [59]

Abortion symptoms that can lead to additional health risks:

  • To provide the necessary treatment, an accurate assessment of an unsafe abortion is critical. Some signs and symptoms that require immediate attention by a licensed health care provider include: abdominal pain, vaginal infection, abnormal vaginal bleeding, shock (collapse of the circulatory system).[59]
  • It is difficult to diagnose complications that result from an unsafe abortion. A woman with an extra-uterine or ectopic pregnancy may have symptoms similar to those of incomplete abortion. Therefore, it is important for health care providers to refer individuals they are unsure about to a facility where a definitive diagnosis can be made and care can be provided.[60]

Complications and their treatments include:

  • Infection: antibiotics prescribed by a health care provider and removing tissue from the affected area.
  • Hemorrhage: swift treatment by a health care provider is imperative, as delays can be fatal.

Damage to the genital tract or internal organs: Admission to a health care facility is imperative, any delay can be fatal.[61]

Treatment of complications

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Regardless if an abortion was legal or illegal, health care providers are required by law to provide medical care to patients, as it may be life-saving. In some cases, treatment for abortion complications may be administered only when the woman provides information about the abortion and any and all persons that were involved.[62] In areas where abortion is illegal, people seeking care for complications of illegal abortions may face legal consequences. This may deter people from seeking life-saving care.[62]

Globally, there is a high burden of complications from unsafe abortions.[63] The costs of treating the complications can be significant in developing countries, where, in 2011, 98% of unsafe abortions occurred.[64] An estimated 5.3 million women worldwide have developed complications or disabilities from unsafe abortion, which may be either temporary or permanent.[65] Unsafe abortions cause an estimated 5 million lost disability-adjusted life years each year by women of reproductive age.[66]

Unsafe abortion cases in the U.S. post-Dobbs v. Jackson

[edit]

In June 2022, the United States Supreme Court’s decision Dobbs v. Jackson Women’s Health Organization overturned the federal right to abortion previously established in Roe v. Wade in 1973 and Planned Parenthood v. Casey in 1992. The Dobbs decision eliminated the federal right to abortion, returning abortion regulation to the states. In the U.S., various state laws prohibit physicians from performing or inducing an abortion after a fetal heartbeat is detected (typically at 6 weeks) leading to delayed dilation and curettage (D&C) procedures for individuals seeking miscarriage care or unsafe abortion complication care. As recently as 2023, in Oklahoma, Jaci Statton seeking a surgical abortion due to a cancerous molar pregnancy was told by hospital staff that doctors could not see her until her condition was “crashing,” or if her blood pressure was elevated to the point of imminent heart attack.[67]

The Georgia Living Infants Fairness and Equality Act (LIFE Act) of 2019 is an example of such a law – doctors are prohibited from using medical instruments with the purpose of terminating a pregnancy, and any doctor violating the law by performing an abortion procedure while a fetal heartbeat can still be detected could be prosecuted with a felony. In 2022, Amber Nicole Thurman, a healthy 28-year-old medical assistant and mother from Georgia, sought a surgical abortion while 9 weeks pregnant at a clinic in North Carolina, the nearest state where abortion at that stage was still legal. However, Thurman was late and missed the appointment due to overhaul from other patients from states with abortion bans. Thurman was instead prescribed a medication abortion by the North Carolina clinic, taking the 2 pills according to the regimen once she returned to Georgia. After taking the second pill, she suffered a dangerous complication that left remaining fetal tissue in her uterus. She arrived at Piedmont Henry Hospital where doctors noted her critically elevated white blood cell count, critically low blood pressure, and diagnosed her with acute severe sepsis. Prior to the LIFE Act, the standard of care would be to provide a D&C, but doctors were forced to withhold care until she went into organ failure. Wanting to keep her for observation in case of further emergency, they provided blood pressure medication to treat the low blood pressure. Twenty hours later, her condition deteriorated enough to warrant the procedure. Surgeons decided that she not only needed a D&C, but also open abdominal surgery to repair her bowel as a complication from the blood pressure medication, along with a hysterectomy. Thurman ultimately died during surgery.[68]

Another example of such a law is Texas Senate Bill 8 (SB8), also known as the Heartbeat Act of 2021. In 2024, NBC News reported 36-year-old Texas woman Amanda Zurawski was initially refused an abortion due to complications at 18 weeks pregnant, until complications increasingly became life-threatening and doctors were compelled to perform an abortion, which at that point, incurred serious infections that led to severe sepsis.[69]

Telehealth medication abortion

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In recent years, telemedicine has been used to send medication to patients seeking medication abortion in areas that are remote, have strict abortion laws, or lack ultrasound resources and trained providers. In the past, such individuals were forced to seek abortion in inconvenient places, incurring large out-of-pocket medical and travel expenses, or revert to unsafe, self, and/or home abortion. Most notably, after the United States’ Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, the proportion of people traveling to another state to obtain abortion services rose from 6% in 2011 to 20% in 2023.[70]

In 2024, a study from the University of California, San Francisco reported that telehealth services allowed 43% of those seeking abortions to receive timely abortion care in areas where abortion is legalized.[71] Furthermore, 98% of those receiving telehealth medication abortion had complete abortions with no adverse events or complications.[72]

See also

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References

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  65. ^ Atuhaire S (October 2019). "Abortion among adolescents in Africa: A review of practices, consequences, and control strategies" (PDF). The International Journal of Health Planning and Management. 34 (4): e1378 – e1386. doi:10.1002/hpm.2842. PMID 31290183. S2CID 195871358. Archived from the original (PDF) on 2022-05-30.
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  67. ^ Simmons-Duffin, Selena (25 April 2023). "In Oklahoma, a woman was told to wait until she's "crashing" for abortion care". NPR.
  68. ^ Surana, Kriti (9 October 2024). "Under Georgia's abortion ban, she died after delayed care". ProPublica.
  69. ^ NBC News (25 February 2024). ""We want kids more than anything" Woman suing Texas plans to move embryos out of state".
  70. ^ Guttmacher Institute (2023). "The high toll of US abortion bans: nearly one in five patients now traveling out of state for abortion care".
  71. ^ ANSIRH (13 May 2024). "Abortion pills by mail are safe and effective, study shows". Advancing New Standards in Reproductive Health, UCSF.
  72. ^ ANSIRH (8 November 2024). "Abortion seekers, particularly those who must travel out of state are at higher risk of incurring catastrophic health expenditures". Advancing New Standards in Reproductive Health, UCSF.
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