This report provides estimates of the number of unsafe abortions and associated Unsafe abortion mortality for the year 2008. Overall, 21.6 million unsafe abortions are estimated to have taken place in 2008, with a lower limit of 20.8 million and the upper limit estimate of 22.4 million. There were an estimated 47 000 maternal deaths due to unsafe abortion Global and regional estimates of procedures in 2008. The report presents regional and global rates and ratios of unsafe abortions per 1000 women in the reproductive age of 15–44 years and per 100 live the incidence of unsafe abortion births, respectively. These measures show the gravity of the problem of unsafe abortion globally and across geographical regions. The report also examines the trends in unsafe and associated mortality in 2008 abortion over time and notes the regions where safe abortions have become more accessible recently. Relevant background information is provided on the legal framework of induced abortion, fertility transition, unplanned pregnancy, unmet need for family planning and contraceptive prevalence. Barriers to safe abortion services and care for women who experience complications due to an unsafe abortion are discussed, as are the health consequences of unsafe abortion. This is the sixth update since the first that was undertaken by WHO in 1990. SIXTH EDITION For more information, please contact: Department of Reproductive Health and Research World Health Organization ISBN 978 92 4 150111 8 Avenue Appia 20, CH-1211 Geneva 27 Switzerland Fax: +41 22 791 4171 E-mail: [email protected] www.who.int/reproductivehealth Unsafe abortion Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008 Sixth edition WHO Library Cataloguing-in-Publication Data Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. -- 6th ed. 1.Abortion, induced - epidemiology. 2.Abortion, induced - mortality. 3.Review literature. I.World Health Organization. ISBN 978 92 4 150111 8 (NLM classification: WQ 440) © World Health Organization, 2011 All rights reserved. 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Printed in Preface This sixth edition of the WHO Global and regional estimates of unsafe abortion and associated mortality is intended for policy-makers and programme managers, health workers and nongovernmental organizations in the area of sexual and reproductive health, researchers, groups and individuals concerned with unsafe abortion as well as others interested in information on unsafe abortion. More details of the data and methods used in the estimates are given in Annex 1. A background to and characteristics of unsafe abortion are presented in Chapter 1. To better understand the levels and trends in unsafe abortion, the legal context of abortion and barriers both to abortion services and to medical care for women who have had an unsafe abortion and experience complications are described in Chapters 2 and 3. Chapter 4 covers interactions in abortion, unplanned pregnancy, contraceptive use and failure and unmet need for contraception; as well as the role that abortion plays in the transition from high to low fertility levels. The health consequences of unsafe abortion and the global burden for women and for society are examined in Chapter 5. The distinction in rates and ratios when calculated for all countries or for countries with evidence of unsafe abortion are explained in Chapter 6. The global incidence and subregional differentials are presented in Chapter 7 with an in-depth analysis of the levels and trends. The geographical regions and subregions referred to in this report are those classified by the United Nations Population Division (UNPD). Chapter 8 presents the mortality estimates. The report highlights the urgency in preventing unsafe abortion and concludes (Chapter 9) with policy and programme recommendations to reduce unsafe abortion. Acknowledgements This report was developed by Elisabeth Åhman (WHO consultant) and Iqbal Shah (WHO) on the basis of information compiled by the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP). Special thanks are extended to: ICF Macro International staff Elliott Hoel, Ladys Ortiz, Albert Themme and Vinod Mishra for special tabulations of Demographic and Health Survey (DHS) data; Colin Mathers, Doris Mafat and Mie Inoue of the WHO Information, Evidence and Research (IER) Cluster for providing assistance; Kelly Culwell of the International Planned Parenthood Federation (IPPF) and Rupsa Mallik of the IPPF South Asia Regional Office for sharing reports and experiences; Susheela Singh of the Guttmacher Institute for sharing documents, reviewing information and for her advice; Aníbal Faúndes of the International Federation of Gynecology and Obstetrics (FIGO) for sharing information on the FIGO Working Group on the Prevention of Unsafe Abortion and its Consequences; as well as numerous colleagues in Geneva and around the world who generously shared data and information. Definitions Contraceptive prevalence (CPR): Percentage of married or cohabiting women of reproductive age (15–49 years) using any method of contraception. Unmet need for family planning (%): Women with unmet need are those who were fecund but were not using any method of contraception at the time of the survey, and yet reported not wanting any more children or wanting to delay the next child. Data pertain to women in union. (A union involves a man and a woman regularly cohabiting in marriage or a marriage-like relationship.) Total fertility rate per woman (TFR) aged 15–44 years: TFR is the average number of live births a woman would have by the end of her reproductive life if she were subject, throughout her life, to the age-specific fertility rates observed in a given year. Unsafe abortion rate: The unsafe abortion rate is the number of unsafe abortions per 1000 women aged 15–44 years in a year. This measure describes the level of unsafe abortions in a population. Unsafe abortion ratio: The unsafe abortion ratio is the number of unsafe abortions per 100 live births (as a proxy for pregnancies)a in a year. The unsafe abortion ratio indicates the likelihood that a pregnancy will end in unsafe abortion rather than a live birth. Per cent of maternal deaths due to unsafe abortion: The number of unsafe abortion deaths per 100 maternal deaths for all causes. This measure describes the relative importance of unsafe abortion as a cause of maternal death. Where the maternal mortality ratio is relatively low and other causes of maternal deaths have already been substantially reduced, a small number of unsafe abortion deaths may account for a significant percentage of maternal deaths. The interpretation of this measure is, therefore, not straightforward and it is not useful for comparison purposes. The number of unsafe abortion deaths: These are estimated from the number of all estimated maternal deaths.2–6 New estimates of maternal deaths have recently been released for 2008.6 Unsafe abortion case-fatality rate: The unsafe abortion case–fatality indicates the estimated number of deaths per 100 000 unsafe abortions. This rate shows the mortality risk associated with unsafe abortion. Unsafe abortion indicators: rates and ratios are calculated for all countries, unless indicated to the contrary. Indicators may be calculated for two differing regional groupings of countries: (1) all countries in the region or subregion, whether they show evidence of unsafe abortion or not; or (2) only the countries with evidence of unsafe abortion, thereby excluding from the denominator the populations of countries where there is no evidence of unsafe abortion for rate and ratio calculations. These countries do not report unsafe abortions (numerator) and therefore their populations appropriately are not included in the denominator. (See Section 6.1 for further details.) Unsafe abortion mortality ratio: The unsafe abortion mortality ratio is the number of deaths due to unsafe abortion per 100 000 live births.a This measures the risk of a woman dying due to unsafe abortion relative to the number of live births. a The number of live births serves as a proxy for the number of pregnancies. A more appropriate denominator would be the total number of pregnancies (live births, stillbirths, induced and spontaneous abortions, ectopic pregnancies), but this figure is rarely available. Live births are therefore used in the denominator for international comparisons. Acronyms AGI Alan Guttmacher Institute CDC Centers for Disease Control and Prevention, United States DHS Demographic and Health Surveys HCM hospitalization complications method ICPD International Conference on Population and Development (ICPD), Cairo, Egypt, 1994 ICPD+5 Five-year Review and Appraisal of the Programme of Implementation of the International Conference on Population and Development, New York, 1999 RAMOS reproductive age mortality studies RRT randomized response technique UN United Nations UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UNPD United Nations Population Division WHO World Health Organization Table of contents Executive summary ..................................................................................................................................................1 1. Background .........................................................................................................................................................2 2. Legal context of abortion ....................................................................................................................................3 3. Barriers to accessing safe abortion services .....................................................................................................7 4. Fertility transition, unplanned pregnancy, contraceptive prevalence and unmet need for family planning ..10 5. Health consequences of unsafe abortion and impact on health services ......................................................14 6. Estimating unsafe abortion incidence and mortality ........................................................................................15 6.1 Selecting the denominator for rates and ratios: all countries versus countries with evidence of unsafe abortion................................................................................................................15 6.2 Estimating subregional, regional and global incidence of unsafe abortion and associated mortality ............................................................................................................................17 6.3 Comparison with 2003 and earlier estimates .....................................................................................17 7. Regional and global incidence of unsafe abortion ..........................................................................................18 7.1 Unsafe abortion globally and by major regions ..................................................................................18 7.2 Unsafe abortion estimates for regions and subregions in 2008 .........................................................18 7.3 Trends in unsafe abortion ....................................................................................................................23 8. Regional and global mortality due to unsafe abortion .....................................................................................27 8.1 Estimated global numbers of maternal deaths due to unsafe abortion and unsafe abortion mortality ratios ......................................................................................................................27 8.2 Case fatality of unsafe abortion ..........................................................................................................30 9. Conclusions .......................................................................................................................................................31 References ..............................................................................................................................................................32 Annexes ..................................................................................................................................................................37 Annex 1. Estimating the annual incidence of unsafe abortion and associated mortality ..................................39 Data on unsafe abortion ...............................................................................................................................39 Data collection for 2008 estimates ..............................................................................................................39 Estimating the incidence of unsafe abortion ................................................................................................40 Estimating unsafe abortion mortality ...........................................................................................................45 References ..................................................................................................................................................48 Annex 2. Countries and territories grouped according to the United Nations Population Division classification of regions .........................................................................................................................................51 Country listing by level of development ......................................................................................................51 Country listing by geographical region ........................................................................................................52 Annex 3. Estimates of the incidence of unsafe abortion and associated mortality, by WHO Regions, 2008 ....54 Annex 4. WHO Regions and Member States ........................................................................................................56