Safe abortion:

a spouse and to enter into marriage only with their
free and full consent; the right of access to relevant
health information; and the right of every person
to enjoy the benefits of scientific progress and its
applications (12). To realize these rights, and to
save women’s lives, programmatic, legal and policy
aspects of the provision of safe abortion need to be
adequately addressed, as elaborated further in the
following chapters.
1.3 Pregnancies and abortions
Among the 208 million women estimated to become
pregnant each year worldwide, 59% (or 123 million)
experience a planned (or intended) pregnancy
leading to a birth or miscarriage or a stillbirth (4).
The remaining 41% (or 85 million) of pregnancies are
unintended.
Because of increased contraceptive use, the pregnancy
rate worldwide has fallen from 160 pregnancies
per 1000 women aged 15–44 years in
1995 to 134 per 1000 women in 2008 (4). Rates of
intended and unintended pregnancies have fallen
from, respectively, 91 and 69 per 1000 women aged
15–44 years in 1995 to 79 and 55 per 1000 women
aged 15–44 years in 2008. More significantly, the rate
of induced abortion has declined from 35 per 1000
women aged 15–44 years in 1995 to 26 per 1000
women aged 15–44 years in 2008. This decline has
been largely due to a fall in the rate of safe abortion,
while the rate of unsafe abortion has remained
relatively constant since 2000 at around 14 per 1000
women aged 15–44 years (13). The absolute number
of unsafe abortions was estimated at about 20 million
in 2003 and 22 million in 2008. The proportion of all
abortions that are unsafe has increased from 44% in
1995 and 47% in 2003 to 49% in 2008 (13). Almost
all unsafe abortions occur in developing countries,
Safe abortion care: the public health and human rights rationale
where maternal mortality rates are high and access
to safe abortion is limited.
1.4 Health consequences of unsafe
abortion
The health consequences of unsafe abortion depend
on the facilities where abortion is performed; the
skills of the abortion provider; the method of abortion
used; the health of the woman; and the gestational
age of her pregnancy. Unsafe abortion procedures
may involve insertion of an object or substance (root,
twig or catheter or traditional concoction) into the
uterus; dilatation and curettage performed incorrectly
by an unskilled provider; ingestion of harmful substances;
and application of external force. In some
settings, traditional practitioners vigorously pummel
the woman’s lower abdomen to disrupt the pregnancy,
which can cause the uterus to rupture, killing
the woman (14). The consequences of using certain
medicines, such as the prostaglandin analogue misoprostol,
in incorrect dosages for inducing abortion
are mixed, though there is some evidence that even
an incorrect dosage can still result in lowering the
number of severe complications and maternal deaths
(15–17).
Deaths and disability related to unsafe abortion are
difficult to measure. Given that these deaths or complications
occur following a clandestine or illegal procedure,
stigma and fear of punishment deter reliable
reporting of the incident. It is especially difficult to get
reliable data on deaths from unsafe second-trimester
abortions (18). Moreover, women may not relate their
condition to a complication of an earlier abortion (19).
Therefore, maternal deaths resulting from unsafe
abortions are grossly underreported. Complications
of unsafe abortion include haemorrhage, sepsis,
peritonitis, and trauma to the cervix, vagina, uterus
Safe abortion: technical and policy guidance for health systems 19