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International Journal of Gynecology and Obstetrics 115 (2011) 121126

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International Journal of Gynecology and Obstetrics


j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o

REVIEW ARTICLE

New estimates and trends regarding unsafe abortion mortality


' Elisabeth A hman, Iqbal H. Shah
Preventing Unsafe Abortion, Special Program of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland

a r t i c l e

i n f o

a b s t r a c t
Background: The 19902008 estimates for the maternal mortality associated with unsafe abortion require a re-examination. Objective: To provide the latest estimates of the mortality associated with unsafe abortion and to examine trends within the framework of new maternal mortality estimates. Search strategy: Extensive search of databases and websites for country- and region-specic data on unsafe abortion. Selection criteria: Reports, papers, and websites with data on unsafe abortion incidence and mortality. Data collection and analysis: Earlier published estimates for the unsafe-abortion-related mortality were recalculated by country for 1990, 1997, 2000, and 2003 to harmonize with the new maternal mortality estimates. The resulting estimates were aggregated to give subregional, regional, and global gures, including those recently estimated for 2008. Main results: In 2008, unsafe abortions accounted for an estimated 47 000 maternal deaths, down from 69 000 in 1990. Globally, the unsafe-abortion mortality ratio has declined from 50 in 1990 to 30 in 2008. The overall burden of unsafe abortion mortality continues to be the highest in Africa. Conclusions: Important gains have been made in reducing maternal deaths attributable to unsafe abortion. However, 1 in 8 maternal deaths globally and 1 in 5 maternal deaths in Eastern Africa continue to be attributable to unsafe abortion. Averting these preventable deaths can contribute to achieving Millennium Development Goal number 5 of improving maternal health. 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Article history: Received 2 February 2011 Received in revised form 22 May 2011 Accepted 27 July 2011 Keywords: Case fatality Developing countries Maternal mortality Unsafe abortion

1. Introduction The WHO denes unsafe abortion as a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both [1]. Unsafe abortions are both widespread and a signicant cause of maternal deaths in developing countries. When faced with an unwanted pregnancy and safe and legal abortion is unavailable or difcult to access, many women turn to unskilled providers or attempt to abort on their own. It is estimated that, globally, 14 of 1000 women aged 1544 years had an unsafe abortion in 2008 [2]. Unlike other causes of maternal death, mortality attributable to unsafe abortion is entirely preventable. Unsafe abortions and the associated mortality could be largely avoided if unplanned pregnancies were prevented through effective family planning and if safe abortion services were available to avert unwanted births from accidental pregnancies among contraceptive users and unintended pregnancies among nonusers of contraceptives and victims of rape or incest. Measurement of the incidence and mortality of unsafe abortion goes back to Christopher Tietze's groundbreaking work examining
Corresponding author at: Department of Reproductive Health and Research, World Health Organization, 1211 Geneva 27, Switzerland. Tel.: + 41 22 791 33 32; fax: + 41 22 791 41 71. E-mail address: shahi@who.int (I.H. Shah).

data on unsafe abortion as a cause of maternal deaths in the 1930s and 1940s in the USA. Tietze relied on data of abortions with and without septic condition, stressing the close association between illegally induced abortions and fatal infection [3]. Deaths attributable to septic abortion corresponded to 17% of all maternal deaths in 1935, 15% in 1940, and 10% in 1945, while the maternal mortality ratio (MMR) fell steeply from 582 to 207 per 100 000 live births [46]. The rapid decline in maternal and septic-abortion deaths during this period is in large part attributable to increasing access to treatment of infections with penicillin. Then, as now, mortality attributable to septic abortion is the tip of the iceberg of the consequences of unsafe abortion. Other causes of death attributable to unsafe abortion include bleeding and organ damage. Unsafe abortion is also associated with short- and long-term morbidity, including infertility [7]. The rst attempt at estimating the global mortality associated with unsafe abortion was made in 1980 by Roger Rochat. Relying on an International Planned Parenthood Federation estimate of 16 million unsafe abortions in 65 Asian, African, Middle Eastern, and Latin American countries and assuming a case fatality rate of 500 deaths per 100 000 procedures in those countries Rochat estimated that 84 000 maternal deaths are attributable to unsafe abortion [8]. A slightly different approach was reported in Preventing Maternal Deaths [9], published in 1989. Assumed abortion-related mortality rates of 50 and 500 per million women were applied to numbers of women aged 1544 years by major regions. This calculation arrived at an annual incidence of 125 000215 000 unsafe-abortion-related

0020-7292/$ see front matter 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.05.027

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maternal deaths, corresponding to values as high as 25%50% for the proportion of maternal deaths that are attributable to unsafe abortion. These numbers were widely reported for more than a decade, although in retrospect they do not seem plausible. Others have suggested that more reliable global and regional estimates should be derived from country estimates and that these estimates should be embedded within the overall estimates of maternal deaths [10]. This is how the WHO approached this task. Estimates from the WHO are based on the reported proportions of unsafe-abortion-related deaths among all maternal deaths by country. The rst WHO estimates for the incidence of unsafe abortion and the associated mortality were calculated globally and by UN-dened regions for 1990 [11]. Using a country-by-country approach, framed by the overall maternal mortality estimates at the time, a global gure of 70 000 deaths from unsafe abortion procedures was estimated. Given the inherent difculty in estimating the number of deaths for unsafe abortion and allowing for a margin of error, it was considered that there were between 50 000 and 100 000 unsafe abortion deaths per year [11]. Despite this imprecision, for the rst time an evidence-based magnitude had been established for these needless deaths, almost all of which occurred in developing countries. Updates using the same methodology were made for 1997, 2000, 2003, and 2008 [2,1214]. Data on the global distribution of causes of maternal death were rst collected for 1990 in the context of the rst Global Burden of Disease study [15]. This exercise was repeated for 2004 [16]. Unsafe abortion was the third leading cause of maternal death in 1990 and the second leading cause of death in 2004, accounting for 13% of all maternal deaths (Table 1). Deaths attributable to unsafe abortion are caused mainly by severe infections, bleeding, or organ damage [17]. Unsafe abortion is also associated with long-term health consequences such as infertility and, more often, short-term illnesses [18]. The new estimates of maternal mortality for 19902008 released by WHO, UNICEF, UNFPA, and the World Bank in 2010 [19] required a review and re-analysis of the previous estimates of unsafe abortion mortality so that the estimates during this period corresponded to each other consistently. Unsafe abortion mortality is part of overall maternal mortality and, therefore, the revision of the latter called for the appropriate realignment and re-estimation of the former. The objectives of the present paper were to provide the latest estimates of unsafe-abortion-related maternal deaths and to examine the trends over time. 2. Materials and methods For this paper, we recalculated the WHO 1990 [11], 1997 [12], 2000 [13], and 2003 [14] unsafe abortion mortality estimates framed by the new maternal mortality estimates [19], while providing the new estimates for 2008 [2]. The same approach to the estimation was used at each occasion. In brief, relying mainly on the search word abortion, papers and reports were identied from bibliographic databases, conference papers, data reported to WHO headquarters and regional ofces, and information reported by national authorities

Table 1 Causes of maternal death (global data) [15,16]a. Cause of death Hemorrhage Sepsis Unsafe abortion Eclampsia/hypertension Obstructed labor Other direct and indirect causes
a b

1990 25 15 13 13 8 26

2004 27 12 13 12 6 31

Values are given as percentage. Other direct causes include ectopic pregnancy, embolism, and anesthesia-related complications; indirect causes include anemia, malaria, and heart disease.

and nongovernmental organizations. These were systematically screened for signicant information relevant to unsafe abortion and related mortality. The signicance of internet searches has increased over time, also allowing for pointed country-specic searches. Reports and papers were assessed for the scientic rigor of the study, and the relevant information and data were included in a database. Percentages of unsafe-abortion-related deaths as a cause of maternal mortality were generated rst by country. Maternal mortality estimates by country, developed and modeled independently from estimates for the incidence of unsafe abortion and its mortality, provide the envelope for calculating the proportionate numbers of unsafe-abortion-related deaths. The numbers of unsafe-abortionrelated deaths were then aggregated to subregional, regional, and global numbers. Since 1990, maternal mortality estimates have been produced by the Maternal Mortality Estimation Inter-agency Group, which consists of the WHO as the lead agency, the United Nations Population Fund, UNICEF, and the World Bank. The estimates for 19902005 were made available at 5-year intervals (1990 [20], 1995 [21], 2000 [22], and 2005 [23]). However, in 2010, new maternal mortality gures for 2008 were published, in addition to revised gures for 1990, 1995, 2000, and 2005 [19]which were lower than those previously reported. The new gures were obtained with a new and more advanced method of estimating the maternal mortality. In addition, there was a shift from estimating the maternal mortality in a single reference year to applying the same methodology to several reference years over a specied time interval. Estimates of the mortality of unsafe abortion are calculated as fractions of the estimated numbers of maternal deaths. The numbers of unsafe-abortion-related deaths published in previous updates are therefore also higher than those presented in this paper, which are calculated on the basis of the revised and much lower maternal mortality estimates for the period 19902008. The new estimates [19], which supersede the earlier ones, show a 34% decline globally in the MMR between 1990 and 2008from 400 in 1990 to 260 in 2008. Given that unsafe-abortion-related deaths are a subset of all maternal deaths, the strengths and limitations of the approach used in estimating the latter have implications for the former. The WHO approach assumes that deaths related to unsafe abortion are as undercounted and misreported as maternal deaths related to other causes. However, the extent of the underreporting of deaths attributable to unsafe abortion is potentially higher than that of maternal deaths attributable to any other cause, given the social stigma and the legal repercussions associated with unsafe abortion, and unsafe-abortion-related mortality estimates may, therefore, be underestimated. For example, because of the stigma linked to abortion, the woman may not volunteer any information about her abortion attempt when seeking care for unsafe-abortion-related complications. In most instances, it is medically difcult to distinguish between an induced and a spontaneous abortion unless there is evidence of interference or the woman volunteers the information. It is also assumed that abortion-related deaths occur mainly or exclusively as a result of unsafe abortions because spontaneous abortions cause death only rarely the mortality rate is estimated to be 1 per 100 000 spontaneous abortions [24]. Estimates of the incidence and mortality of unsafe abortion in individual countries were calculated solely for the purpose of aggregating the data at regional and global levels. Aggregated estimates are relatively robust; nevertheless, estimates of the incidence and mortality of unsafe abortion inherently contain some degree of uncertainty. They should be considered as best estimates that are based on the information available at the time of estimation. The data on which the unsafe-abortion-related mortality estimates are based have come from 3 sources, namely national statistics, community studies, and hospitals. Where available, information from community studies has been used. However, for many countries the data are hospital-based, and in these settings, the accuracy of the

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data depends on the disposition of women to seek hospital care when faced with abortion-related complications. To arrive at national estimates, hospital and nonhospital estimates were weighted according to the hospitalization rates for deliveries, and urban and rural estimates were weighted according to the percentages of the population that lived in urban/rural areas. The mortality associated with unsafe abortion in 2008 [2] was estimated for 100 of 136 countries with evidence of unsafe abortion. These countries accounted for almost 85% of all maternal and unsafeabortion-related deaths, 71% of all global births, and 61% of all women aged 1544 years. For the remaining 36 countries with evidence of unsafe abortion (including a few small countries for which the maternal mortality was not assessed), no data could be traced from which to assess the mortality associated with unsafe abortion, even though information was available on the incidence of unsafe abortion. These countries were assigned the regional average percentage of maternal deaths attributable to unsafe abortion. They account for 14% of all maternal deaths, 16% of all deaths attributable to unsafe abortion, 6% of all births, and 4% of all women aged 1544 years. Globally, only 3% of all maternal deaths occur in 60 countries where there is no evidence of unsafe abortion. Countries with both legal and unsafe abortions contributed only small numbers of deaths from unsafe abortion, with the exception of India, where large numbers of unsafe abortions reportedly take place. Estimates for the mortality associated with unsafe abortion are available for 1990 [11], 1997 [12], 2000 [13], 2003 [14], and 2008 [2]. For the present paper, the estimated percentages of maternal deaths attributed to unsafe abortion for these years were applied to the overall MMR of each country as estimated for 1990, 2000, and 2008 [19]. For 1997, the average MMR for 1995 and 2000 was calculated by country; the MMR for 2003 is the average value for 2000 and 2005. The unsafe abortion mortality ratios so derived were applied to estimates of live births for 1990, 1997, 2000, and 2003 from the UN

Population Division's 2008 edition of population estimates [25] to calculate the regional and global number, ratio, and percentage of deaths associated with unsafe abortion. To be able to compare trends over the 5 time periods, regions were re-arranged to the current composition; for example, former Soviet Union countries and Yugoslavia are attributed to their current regions. 3. Results 3.1. Mortality of unsafe abortion in 2008 According to the WHO, there were 47 000 deaths globally due to unsafe abortion in 2008; the majority of unsafe-abortion-maternal deaths in 2008 took place in Africa and Asia, with much smaller numbers reported for Latin America (Table 2) [2]. Globally, the proportion of maternal deaths attributable to unsafe abortion has remained close to 13% over time [2]; the global mortality associated with unsafe abortion therefore declines at approximately the same rate as the maternal mortality overall. However, the pace of decline varies by region and subregion, depending on the country-specic circumstances surrounding unsafe abortion and access to care. The unsafe-abortion mortality ratiothat is, the number of unsafeabortion-related deaths per 100 000 live births (the equivalent of the MMR)is a more appropriate indicator than both the number and the percentage of unsafe-abortion-associated maternal deaths for analyzing change over time and across regions. The risk of death caused by unsafe abortion in 2008 was 30 per 100 000 live births globally and 40 per 100 000 live births in developing countries [2] (Table 2). At 80 per 100 000 live births, the risk associated with unsafe abortion for the least developed countries was twice that for developing countries; the gure for Sub-Saharan Africa is the highest at 90 per 100 000. The highest unsafe-abortion mortality ratio is found in Eastern Africa (100 per 100 000 live births), whereas the ratios in Western Africa

Table 2 Incidence and mortality of unsafe abortion in 2008 [2] a. Number of maternal deaths attributable to unsafe abortion Worldwide Developed countries b Developing countries Least developed countries Sub-Saharan Africa Africa Eastern Africa Middle Africa Northern Africa Southern Africa Western Africa Asia b Eastern Asia c South/Central Asia Southeastern Asia Western Asia Europe Eastern Europe Northern Europe c Southern Europe c Western Europe c Latin America and the Caribbean Caribbean Central America South America Northern America Oceania b Australia/New Zealand c
a b c

Ratio of maternal deaths attributable to unsafe abortion (per 100 000 live births) 30 1 40 80 90 80 100 80 30 40 80 20 30 20 10 1 3 10 20 8 10 30

Proportion of maternal deaths that are attributable to unsafe abortion (%) 13 4 13 14 14 14 18 12 12 9 12 12 13 13 16 8 11 12 11 9 13 12

Number of unsafe abortions 21 600 000 360 000 21 200 000 4 990 000 5 510 000 6 190 000 2 430 000 930 000 900 000 120 000 1 810 000 10 780 000 6 820 000 3 130 000 830 000 360 000 360 000 4 230 000 170 000 1 070 000 2 990 000 18 000

Rate of unsafe abortions (per 1000 women aged 1544 years) 14 1 16 27 31 28 36 36 18 9 28 11 17 22 16 2 5 31 18 29 32 8

47 000 90 47 000 23 000 28 500 29 000 13 000 4400 1500 500 9700 17 000 14 000 2300 600 90 90 1100 100 200 700 100

The classication of geographical regions and subregions follows the system used by the UN Population Division [25]; the data have been rounded. Japan, Australia, and New Zealand have been excluded from the regional estimates, but are included in the total for developed countries. No estimates are provided because the incidence was negligible.

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Table 3 Unsafe-abortion mortality ratio (number of unsafe-abortion-related maternal deaths per 100 000 live births) a. 1990 Worldwide Developed countries Developing countries Africa Eastern Africa Middle Africa Western Africa Southern Africa Northern Africa Asia b South/Central Asia Southeastern Asia Western Asia Europe Eastern Europe Northern Europe Southern Europe Latin America and the Caribbean Caribbean Central America South America 50 5 60 100 110 80 140 30 20 50 80 50 10 8 20 1 2 30 60 20 40 1997 40 2 50 90 110 80 110 60 20 40 60 40 10 4 10 1 1 20 50 20 20 2000 40 2 50 90 110 90 100 40 20 40 60 40 10 4 10 0 1 20 30 10 20 2003 40 1 50 100 120 100 110 40 40 30 50 30 10 1 2 0 1 10 20 10 10 2008 30 1 40 80 100 80 80 40 30 20 30 20 10 1 3 0 0 10 20 8 10

a The classication of geographical regions and subregions follows the system used by the UN Population Division [25]; regions where the incidence of unsafe abortions is negligible have been omitted from this table; the data have been rounded. b Japan, Australia, and New Zealand have been excluded from the regional estimates, but are included in the total for developed countries.

1990 to 58 000 in 1997 and 2000, 56 000 in 2003, and 47 000 in 2008. The data show an increased momentum between 2003 and 2008, which is partly attributable to improvements in maternal health services and possibly also to an increasing reliance on medical abortion. However, even as gains are made, the decline is far from the Millennium Development Goal number 5 target of a 75% reduction in the MMR by 2015. Unsafe abortions account for tens of thousands of preventable deaths. The global, regional, and subregional unsafe-abortion mortality ratios have also gradually decreased over time (Table 3). However, in Africa this was noticeable only between 2003 and 2008. Africa had the highest burden of maternal mortality associated with unsafe abortion and of maternal mortality overall throughout the whole period under investigation. The unsafe-abortion mortality levels for Eastern, Middle, and Western Africa are strikingly higher than those for Northern Africa and Southern Africa. In addition, the decline in the unsafe-abortion mortality ratio between 1990 and 2008 for Africa (a reduction by 15%) is visibly slower than that in other regions. During the same period, the unsafe-abortion mortality ratio in Asia declined by more than 50% and that in Latin America by nearly 70%. The trends in the unsafe-abortion mortality ratio are best captured by looking at the percent annual change (Fig. 1). A small annual reduction of 1% is noticed for Africa, whereas higher annual rates of decline of 4% and more than 6% are seen for Asia and Latin America, respectively. However, the largest improvement in the unsafeabortion mortality ratio is seen in Europe, where deaths associated with unsafe abortion in 2008 are only seen in Eastern Europe. 3.3. The risk associated with unsafe abortion procedures: Case fatality rate Fig. 2 shows the case fatality rate per 100 000 unsafe abortion procedures globally and by major regions. In 2008, the differences between regions were dramatic. The risk of dying from an unsafe abortion procedure in Africa was almost 3 times higher than that in Asia, and more than 15 times higher than that in Latin America. These numbers reect the extent of reliance on unsafe abortion methods and the poor availability of or access to health services should complications of unsafe abortion occur. A comparison with the case fatality rate associated with legally induced abortions in the USA (0.6 per 100 000 procedures [28]) gives yet another perspective. The global case fatality rate associated with unsafe abortion (220 per 100 000) is some 350 times higher, and in Sub-Saharan Africa, the rate is more than 800 times higher, than the rate for legal abortion in the USA.

and Middle Africa are 80 per 100 000 live births each. Northern and Southern Africa show lower ratios of 30 and 40 deaths per 100 000 live births. These ratios are of a similar magnitude to the ratios in Asian subregions, which range from 10 to 30. Although the number of unsafe abortions in Latin America is high, the associated risk of death is relatively low, with an average of 10 unsafe-abortion-related deaths per 100 000 live births (Table 2) [2]. This is closer to the estimate for developed countries and may be attributable to a high, and apparently increasing, reliance on medical abortions [26,27] and a relatively well-developed infrastructure for health care. 3.2. Trends in the mortality associated with unsafe abortion from 1990 to 2008 Globally, the number of unsafe-abortion-related maternal deaths from all causes has declined by one-third since 1990, from 69 000 in

Fig. 1. Number of unsafe-abortion-related maternal deaths per 100 000 live births and annual percent change from 1990 to 2008. Japan, Australia, and New Zealand have been excluded from the regional estimates, but are included in the total for developed countries.

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800
1990

-8
2008 Annual percentage change
680

Unsafe-abortion-related deaths per 100'000 unsafe abortions

600
470 400

-6

400

370 340

-4

220

220 160 80 40 30 30 40 30

200

-2

World

Developed countries

Developing countries

Africa

Asia

Latin America & Caribbean

Europe

Fig. 2. Number of unsafe-abortion-related maternal deaths per 100 000 unsafe abortions and annual percent change from 1990 to 2008. Japan, Australia, and New Zealand have been excluded from the regional estimates, but are included in the total for developed countries.

The risk associated with unsafe abortion procedures has nevertheless decreased substantially in all regions between 1990 and 2008. However, Africa again stands out showing a slower pace in the reduction of the case fatality rate. The rate decreased from 680 in 1990 to 470 in 2008 (a reduction by one-third), corresponding to an annual percent change of just 2% (Fig. 2). In Asia, the case fatality rate in 2008 was 40% lower than that in 1990, with an annual rate of decline of 5%. In Latin America, the case fatality rate at 30 in 2008 was a remarkable one-third of the 1990 level, showing an annual reduction of more than 6%. This rate is similar to that for Europe, which witnessed a decline from 40 to 30 deaths per 100 000 unsafe abortion procedures. It is interesting to note that the mortality risks associated with unsafe abortion in Latin America and Europe have become increasingly similar. In Europe, unsafe abortions are reported only in some parts of Eastern Europe, where a low level of underground unsafe abortions coexists with large numbers of legal abortions. Although the incidence of unsafe abortion in Latin America is high at 31 unsafe abortions per 1000 women aged 1544 years (Table 2), and although induced abortion is legally highly restricted in most countries of the region, the presence of a relatively good infrastructure for health services and an increasing reliance on medical abortion has kept the mortality relatively low in Latin America, and the unsafe abortion case fatality rate is just about equal to that in Europe. However, unsafe abortion remains a more serious problem in some Latin American subregions, which is evident from the fact that the unsafe-abortion mortality ratio in Latin American subregions in 2008 ranged from 8 to 20 per 100 000 live births, compared with 3 per 100 000 in Eastern Europe (Table 2). 4. Conclusions Deaths attributable to unsafe abortion can be prevented by effective contraception, safe abortion services, and postabortion services. The decline in the number of unsafe-abortion-related deaths and in the risk associated with unsafe abortion procedures has been greatest in Latin America, closely followed by Asia. Only minor improvements are noted in Africa, which lags behind other developing country regions. The estimated number of deaths attributable to unsafe abortion decreased from 69 000 in 1990 to 47 000 in 2008 [2]. This corresponds to a 32% reduction, compared with a reduction of 34% for maternal mortality overall [19]; the annual percent decline for maternal mortality is 2.3% [19] and that for unsafe-abortion-related mortality is 2.1%. Even if the decline accelerates, Millennium Development Goal number 5 (improving maternal health with the target of reducing the

MMR by three-quarters between 1990 and 2015) is unlikely to be attained unless drastic efforts are made to address the issue of unsafe abortion and its associated mortalityjust like efforts are being made to reduce other causes of maternal mortality. At the International Conference on Population and Development in Cairo, Egypt, in 1994, a commitment was made to make postabortion care available to women with complications. Simply meeting this commitment could save the lives of many and improve the health of millions of women, especially in developing country regions. Conict of interest The authors have no conicts of interest. References
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