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The Lancet: 25.5 million unsafe abortions take place worldwide every year, new study estimates

The Lancet

Every year, of the 55.7 million abortions that take place worldwide, 25.5 million are unsafe according to a new study published in The Lancet. This means that nearly half of all abortions are unsafe, with the vast majority of these (97%, 24 million) taking place in Africa, Asia and Latin America.

The findings come from a new study led by WHO and the Guttmacher Institute, New York (US) and highlight the need to ensure safe access to abortion to the full extent of the law, particularly in low income countries, as well as the need to replace the use of unsafe methods with safe methods of abortion.

In the study, the authors classified abortion safety as safe, less safe and least safe. The three categories represent the spectrum of conditions under which abortions occur and help to distinguish between the use of misoprostol outside the formal health system (classified as less safe) from the dangerous or least safe abortions performed using traditional, invasive means.

Globally, approximately 55% of all abortions (30.6 million each year between 2010 and 2014) were safe, meaning they were done via a WHO recommended method (medical abortion, vacuum aspiration, or dilatation and evacuation) and provided or supported by a trained individual.

An estimated 30.7% of all abortions (17.1 million) were classified as less safe - for instance if the abortion was done by a trained provider but with an outdated method (eg sharp curettage), or if the abortion was done with a safe method (eg misoprostol) but without the support of a trained person. An estimated 14.4% of all abortions (8 million) were classified as least safe if they were provided by untrained individual using dangerous or invasive methods (eg ingestion of caustic substances, insertion of foreign bodies or use of traditional concoctions).

Almost all abortions in developed countries (87.5%) were safe with similar rates across regions. The exception was Eastern Europe, where the proportion of unsafe abortions was slightly higher (14.2% compared to 6.5% in Western Europe), likely because of the persistence of outdated medical practices such as sharp curettage in the region. Eastern Asia had a similar safety profile to Europe and North America.

The proportion of safe abortions was 25% or less in most regions of Africa and throughout Latin America. In Latin America, however, most unsafe abortions were categorised as less safe rather than least safe, likely reflecting the transition from the use of dangerous traditional methods to the use of misoprostol by women outside of formal health systems. Additionally, health systems in Latin America are more functional than those in Africa.

In contrast, the vast majority of unsafe abortions in Africa were categorised as least safe and were associated with higher rates of death, likely linked to serious complications and poor health infrastructure. The proportion of safe abortions exceeded 50% only in three developing regions (southeastern Asia [59.6%], western Asia [51.5%], and southern Africa [73.5%]).

The research team also considered the context within which abortions were provided, including the availability of adequate facilities and trained personnel, financial access to services, abortion stigma, legality and overall health infrastructure of the country.

Countries with high proportions of safe abortions were also more likely to have less restrictive laws, which might provide a more enabling environment for trained providers and access to safe methods. In the 57 countries where abortion was available on request, 87.4% of all abortions were safe, compared with 25.2% in the 62 countries where abortion was banned or allowed only to save a woman's life or to preserve her physical health. In countries with restrictive laws, nearly one third (31.3%) of abortions were classified as least safe.

"The highest proportions of safe abortions were seen in countries with less restrictive laws, high economic development and well developed health infrastructures suggesting that both the legal framework and overall development of a country plays a role in abortion safety," says lead author Dr Bela Ganatra, WHO [1].

"Our findings call for the need to ensure access to safe abortions to the full extent of the law, particularly in low income regions of the world, and efforts are needed to replace the use of unsafe methods with safe methods. Increasing the availability, accessibility and affordability of contraception can reduce the incidence of unintended pregnancies, and therefore abortions, but it is essential to combine this strategy with interventions to ensure access to safe abortions," adds Dr Ganatra [1].

The authors note that the study does not allow for an analysis of trends over time because it uses a new model to categorise abortion safety into three categories, which reflects a more nuanced description of safety and the increasingly widespread use of misoprostol outside formal health systems in some countries where abortion is legally restricted.

Finally, the authors note the estimates include varying levels of uncertainty because of the limitations around data availability, particularly in countries where abortion is legally restricted and stigma is common, and where drugs are purchased outside of the formal health system.

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NOTES TO EDITORS

The study was funded by UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction; David and Lucille Packard Foundation; UK Government; Dutch Ministry of Foreign Affairs; Norwegian Agency for Development Cooperation.

[1] Quotes direct from authors and cannot be found in the text of the Article.

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