- Email: [email protected]
Critical gaps in universal access to reproductive health: Contraception and prevention of unsafe abortion
International Journal of Gynecology and Obstetrics 110 (2010) S13–S16
Contents lists available at ScienceDirect
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
PRECONGRESS WORKSHOP
Critical gaps in universal access to reproductive health: Contraception and prevention of unsafe abortion Kelly R. Culwell a,⁎, Marcel Vekemans a, Upeka de Silva a, Manuelle Hurwitz a, Barbara B. Crane b a b
International Planned Parenthood Federation, Central Office, London, UK Ipas, Chapel Hill, NC, USA
a r t i c l e Keywords: Abortion Contraception Human rights Maternal mortality Prevention
i n f o
a b s t r a c t Unsafe abortion accounts for a significant proportion of maternal deaths, yet it is often forgotten in discussions around reducing maternal mortality. Prevention of unsafe abortion starts with prevention of unwanted pregnancies, most effectively through contraception. When unwanted pregnancies occur, provision of safe, legal abortion services can further prevent unsafe abortions. If complications arise from unsafe abortion, emergency treatment must be available. Recommendations made on this issue during the Precongress Workshop held prior to the 2009 FIGO World Congress in Cape Town, South Africa, were part of a report that was adopted by the FIGO General Assembly. These recommendations address prevention of unsafe abortion and its consequences and support access to safe abortion care to the full extent allowed by national laws, along with 6 strategies for implementation, including integration of family planning into other reproductive health services, adequate training for providers, task-sharing with mid-level providers, and using evidence to discuss this issue with key stakeholders. © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Unsafe abortion accounts for 13% of maternal mortality [1] and results annually in nearly 70 000 deaths worldwide; 99% of these occur in low-resource countries (35 600 in Sub-Saharan Africa; 28 400 in Asia; and about 2000 in Latin America, the Caribbean, and Oceania combined) with only a few in high-resource regions of the world (under 60 in Europe and North America combined) [1]. Besides mortality, unsafe abortion can be responsible for temporary or permanent disability, including secondary infertility, in millions of women. As we approach 2015, it has been recognized that Millennium Development Goal (MDG) number 5 (reducing maternal mortality and universal access to reproductive health) has seen the least progress of all of the MDGs [2]. Unfortunately, global initiatives focusing on reducing maternal mortality largely ignore unsafe abortion as a significant cause of maternal mortality and morbidity. Unsafe abortion, along with HIV/sexual and reproductive health linkages and adolescent sexual health, was selected as one of the “critical gaps in universal access to reproductive health” to be addressed during the Precongress Workshop held prior to the XIX FIGO World Congress of Gynecology and Obstetrics in October 2009 in Cape Town, South Africa, sponsored by the WHO/FIGO Alliance on ⁎ Corresponding author. International Planned Parenthood Federation, 4 Newhams Row, London SE1 3UZ, United Kingdom. Tel.: +44 20 7939 8273; fax: +44 20 7939 8300. E-mail address: [email protected] (K.R. Culwell).
Women's Health. The Precongress Workshop brought together over 100 of the world's experts in women's health, approximately 40 of whom chose to address the topic of unsafe abortion. The discussion on unsafe abortion focused on 3 areas: preventing unwanted pregnancies; prevention of unsafe abortion; and managing complications of unsafe abortion to prevent morbidity and mortality. 2. Preventing unwanted pregnancies As nearly all unsafe abortions are a result of unwanted pregnancies, prevention of unwanted pregnancy is a logical best option for reducing the number of unsafe abortions. 2.1. Promoting the use of contraception The right to plan one's family and space one's children is specified in Article 16.1 of the United Nations Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) and was reemphasized in the Programme of Action from the International Conference on Population and Development (Cairo, Egypt, 1994) and the Platform for Action from the Fourth World Conference on Women (Beijing, China, 1995). However, it is currently estimated that 215 million women globally who wish to limit or space their childbearing are not using a modern contraceptive method [3]. This unmet need is greatest among the most vulnerable populations with disproportionately high levels among poor, adolescent, and rural women [3].
0020-7292/$ – see front matter © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2010.04.003
S14
K.R. Culwell et al. / International Journal of Gynecology and Obstetrics 110 (2010) S13–S16
The reasons for unmet need are both supply and demand driven. Governments in many countries have failed to make funding for reproductive health a priority in national budgets. Logistics problems along with funding shortages create a lack of commodities in the areas where they are most needed. The Guttmacher Institute and the United Nations Population Fund (UNFPA) estimate that US $6.7 billion annually is needed to meet current and unmet need for contraceptives globally, a figure more than double that of current global investment in family planning [3]. Healthcare providers themselves often impose unnecessary barriers to provision of contraceptive services [4], including denial of a contraceptive method on the basis of age, parity, marital status, or lack of parental or spousal authorization, which can make it more difficult for a woman to obtain and continue with a contraceptive. Moreover, a limited choice of contraceptive methods and poor contraceptive counseling can result in women being given contraceptive methods that are difficult for them to continue. Ideally, internationally accepted evidence-based protocols such as the WHO Medical Eligibility Criteria [5] and Selected Practice Recommendations [6] should be used to create evidence-based practice guidelines at the country level and assist healthcare providers and program managers in appropriate delivery of family planning methods. Reducing the unmet need for contraceptives and unwanted pregnancies is difficult without attention to comprehensive sexual and reproductive health and rights. When women lack autonomy to make decisions for themselves and their families, their access to uninterrupted family planning services is compromised. Provision of correct information is also crucial to combat the myths and misconceptions held by women, their families, and communities about contraceptive methods. Cultural and religious barriers, including disempowerment of women, particularly the poor and those living in rural areas, leads to lack of awareness of the availability of contraceptive methods and inequitable access to services. The taboo surrounding pre-marital sexual activity among young people often leads to discriminatory laws or attitudes among healthcare providers and clinic staff, which deters young people from being able to access contraceptive services as well as comprehensive sexual and reproductive health care. 2.2. Promoting general and sexuality education Education is an important factor in the prevention of unwanted pregnancy and unsafe abortion. Comprehensive sexuality education encourages, where appropriate, a delay in starting sexual activity and results in a reduction in the number of sexual partners and increased condom or contraceptive use [7]. In contrast, there is no evidence that abstinence-only education has any effect on reducing abortion rates. Young people pledging abstinence until marriage will have sex as soon as non-pledgers, but are less likely to protect themselves from unintended pregnancy or sexually transmitted infections [8,9]. 2.3. Eliminating gender-based violence It is a tragic reality that many unsafe abortions are a result of unwanted pregnancies after forced intercourse or violence, especially for women who are young or in other vulnerable circumstances. Women and girls in conflict situations suffer especially when rape is used as a weapon of war. In a multi-country study conducted by WHO, up to 30% of women in some regions reported that their first experience of sexual intercourse was forced or coerced [10]. In addition, the study found that the younger the girl was at the time of sexual initiation, the more likely she was to report her first sexual intercourse was a result of force or coercion [10]. This is particularly significant to the issue of unsafe abortion, since it is estimated that 40% of unsafe abortions in low-resource countries were in women under the age of 25. That number is nearly 60% in Africa [11].
3. Prevention of unsafe abortion: Replacing unsafe abortion by legal safe abortion According to the FIGO Committee for the Study of Ethical Aspects of Human Reproduction and Women's Health, “Providing the process of properly informed consent has been carried out, a woman's right to autonomy, combined with the need to prevent unsafe abortion, justifies the provision of safe abortion” [12]. Only 40% of the world population can access abortion without restriction as to reason, within gestational limits [13]. Everywhere else laws restrict access to safe abortion to a lesser or greater degree [14]. There has been a trend in recent years toward reduced restrictions within abortion laws globally. Of the 21 countries that have changed their abortion laws since 1997, 19 of those reduced restrictions. On the other hand, a few countries have increased their restrictions, including El Salvador and Nicaragua—both eliminating all legal indications for abortion, even when necessary to save a woman's life [15]. While most countries allow safe abortion for conditions endangering women's lives and health, the definition of health used by the World Health Organization, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [16], is rarely applied when interpreting such laws. It is well understood that legal restrictions do not lower the incidence of abortion; thus the abortion rate of 29 per 1000 women of reproductive age in Africa, where abortion is mostly illegal, is similar to that of 28 per 1000 women in Europe, where abortion is generally permitted on broad grounds [17]. The difference is the high death toll in Africa, where the abortions are predominantly unsafe. The arguments for the provision of safe, legal abortion services include those from a public health, human rights, social justice, and even economic point of view. Even if contraceptives are widely available and used, contraceptive methods are not perfect, nor are users. Therefore, there will always be need for safe abortion services when unwanted pregnancies occur. Abortion, when provided in a safe environment by properly trained providers, is one of the safest medical procedures [18]. Safe, legal abortion is an extremely effective way of eliminating unsafe abortion and the deaths and long-term consequences resulting from it [18]. Preventing these deaths could make a significant impact in countries’ efforts to meet the MDG 5 target of a 75% reduction in the maternal mortality ratio by 2015. Failing to provide access to safe abortion services or prosecuting women for seeking abortion services is increasingly recognized as a violation of a woman's right to life, right to health, right to be free from torture and cruel inhuman degrading treatment and punishment, and the right to non-discrimination [19]. In addition, the UN Committee on Torture has held that forcing a woman to carry a pregnancy to term that was a result of sexual violence entails continued violation of her human rights [20]. However, many countries do not allow legal abortion in the case of rape or incest, and for those that do have legal exceptions for these reasons, access to services for these indications is often limited or non-existent. Not only does unsafe abortion carry a heavy human cost, but it also places a burden on health systems that are already financially stretched. The cost to the government health systems of treating complications from unsafe abortion is several times that of contraceptive and safe abortion services. It is estimated that health systems in developing countries expend US $460–550 million per year (in 2006 dollars) to treat severe consequences of unsafe abortion [15]. As noted above, increasing access to comprehensive abortion care will reduce the practice of unsafe abortion and its consequences. Comprehensive abortion care includes pre- and post-abortion counseling, surgical and (where possible) medical drug-induced techniques, and post-abortion care—both emergency services and post-abortion contraception [21]. Post-abortion contraceptive counseling and services, including availability of highly effective long-acting contraceptives (intrauterine devices and implants) and
K.R. Culwell et al. / International Journal of Gynecology and Obstetrics 110 (2010) S13–S16
sterilization, where appropriate, are essential components of postabortion care. These services should necessarily be both youthfriendly and accessible to hard-to-reach segments of the population. 4. Managing complications of unsafe abortion to prevent morbidity and mortality: Provision of quality post-abortion care The stigma associated with abortion in many countries combined with the restrictive legal environment and criminalization of the woman lead to a lack of compassionate, appropriate care of the consequences of unsafe abortion. A recent study from Gabon looked at the delay in care from the time of presentation to the healthcare facility to initiation of care among women who died from various maternity-related causes [22]. For women who died from postpartum hemorrhage or eclampsia, the delay in treatment was just over 1 hour. However, the delay in initiating care for women who died from unsafe abortion complications was nearly 24 hours from the time of presentation to the health facility. Unfortunately, this is the experience of far too many women in low-resource countries who suffer complications from unsafe abortion. Adolescents, unmarried women, or women with HIV may face double or triple stigmatization of being pregnant outside of marriage or with HIV and then again if they choose to end the pregnancy. When these women—or women who are too poor to access care—experience complications of unsafe abortion, they are far less likely to seek or receive treatment for those complications. It is estimated that of the over 7 million women who have complications of unsafe abortion, nearly 40% do not obtain adequate care [15]. The harmful effects of unsafe abortion can be alleviated through the provision of high-quality and timely post-abortion care. This care includes basic treatments that are common in postpartum care, including uterine evacuation (via vacuum aspiration or misoprostol), antibiotics, analgesics, blood transfusion, and uterotonics such as oxytocin. More severe complications will require secondary or tertiary settings where surgical theatres are available, but most of the early or minor complications can be treated in the primary care facility by a trained, mid-level provider. These services simply need to be available, of high quality, and women need to be aware of them and able to access them with minimal delay. As noted above, however, simply having the services in place will not ensure that all complications of unsafe abortion are treated in a timely manner, unless women feel safe in accessing the services and confident that they will receive non-judgmental care. 5. Recommendations The following recommendations for obstetrician-gynecologists and FIGO member societies were presented to the FIGO General Assembly as part of a full report on the proceedings from the PreCongress Workshop on “Critical Gaps in Universal Access to Reproductive Health.” 1. Ensure access to counseling and services for all effective methods of contraception, including emergency contraception, for all women, with special attention to the needs of those who are young, those at risk of HIV, poor, rural, or in other vulnerable groups. 2. Ensure that women with complications of unsafe abortion receive the same quality of care as all other women, nonjudgmental, with minimum delay, and with attention to their other sexual and reproductive health needs. Post-abortion care is part of emergency obstetric care and should be available in all settings. 3. Ensure access to safe abortion care to the full extent allowed by national laws in accordance with FIGO and WHO guidelines on safe abortion, including clear regulations that protect obstetricians
S15
and gynecologists, other healthcare providers, and the women they serve. 4. Strategies to implement these recommendations include: a. Promote integration of family planning with postpartum, abortion, and post-abortion care, in accordance with WHO guidelines and the joint statement on “Family Planning: a Key Component of Post-abortion Care” by FIGO, the International Confederation of Midwives, the International Council of Nurses, and the United States Agency for International Development. b. Ensure that obstetricians and gynecologists receive adequate pre-service, in-service, and on-the-job training on evidencebased practices and technologies for contraception, abortion care, and counseling, as well as on legal, social, and psychological aspects of women's sexual and reproductive health. c. Support task-sharing through the authorization, training, and supervision of general practitioners, midwives, nurses, and other mid-level providers to provide contraceptive and safe abortion and post-abortion care. d. Ensure that all obstetrician/gynecologists and other healthcare providers receive adequate training and sensitization in human rights principles, including sexual and reproductive rights. e. Provide accurate evidenced-based information and accepted ethical principles as a basis for informed dialogue with other key stakeholders, including policy makers, the media, other professional groups, and the public. f. Strengthen capacities of FIGO member societies to provide leadership in collaboration with other stakeholders in helping women to prevent and manage unwanted pregnancies, including access to safe and legal abortion as allowed by law.
Conflict of interest The authors declare no conflict of interest. References [1] World Health Organization. Unsafe abortion: global and regional estimates of incidence of unsafe abortion and associated mortality in 2003. Geneva: WHO; 2007. Available at: http://www.who.int/reproductivehealth/publications/unsafe_ abortion/9789241596121/en/index.html. [2] Rosenfield A, Maine D, Freedman L. Meeting MDG-5: an impossible dream? Lancet 2006;368(9542):1133–5. [3] Singh S, Darroch JE, Ashford LS, Vlassoff M. Adding it up: The costs and benefits of investing in sexual and reproductive health. New York: Guttmacher Institute and United Nations Population Fund (UNFPA); 2009. [4] Brown SS, Burdette L, Rodriguez P. Looking inward: Provider-based barriers to contraception among teens and young adults. Contraception 2008;78(5):355–7. [5] World Health Organization. Medical eligibility criteria for contraceptive use. 4th ed. Geneva: WHO; 2009. Available at: http://whqlibdoc.who.int/publications/2009/ 9789241563888_eng.pdf. [6] World Health Organization. Selected practice recommendations for contraceptive use. 2nd ed. Geneva: WHO; 2004. Available at: http://www.who.int/reproductivehealth/ publications/family_planning/9241562846index/en/index.html. [7] Kirby D. Emerging answers 2007: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy; 2007. Available at: http:// www.thenationalcampaign.org/EA2007/EA2007_full.pdf. [8] Collins C, Alagiri P, Summers T. Abstinence only vs. comprehensive sex education: What are the arguments? What is the evidence? San Francisco: AIDS Policy Research Center & Center for AIDS Prevention Studies. San Francisco: AIDS Research Institute, University of California; 2002. Available at: http://ari.ucsf.edu/ science/reports/abstinence.pdf. [9] Rosenbaum JE. Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers. Pediatrics 2009;123(1):e110–20. [10] World Health Organization. Multi-country study on women's health and domestic violence against women: initial results on prevalence, health outcomes and women's responses. Geneva: WHO; 2005. Available at: http://www.who.int/ gender/violence/who_multicountry_study/en/index.html. [11] Shah I, Ahman E. Age patterns of unsafe abortion in developing country regions. Reprod Health Matters 2004;12(24 Suppl):9–17. [12] FIGO Committee for the study of Ethical Aspects of Human Reproduction and Women's Health. Ethical Aspects of Induced Abortion for Non-Medical Reasons. Ethical Issues in Obstetrics and Gynecology. London: FIGO; 2009. p. 102–4.
S16
K.R. Culwell et al. / International Journal of Gynecology and Obstetrics 110 (2010) S13–S16
[13] Center for Reproductive Rights. The World's Abortion Laws 2008; 2008. New York, Center for Reproductive Rights. Available at: http://reproductiverights.org/sites/ crr.civicactions.net/files/pub. [14] Vekemans M, de Silva U, Hurwitz M. Access to safe abortion. A tool for assessing legal and other obstacles. London: International Planned Parenthood Federation; 2008. Available at: http://www.ippf.org/NR/rdonlyres/6649ED84-2EA1-4C88-8A86CA19BBB19463/0/AbortionLawToolkit.pdf. [15] Singh S, Wulf D, Hussain R, Bankole A, Sedgh G. Abortion Worldwide: A decade of uneven progress. New York: Guttmacher Institute; 2009. Available at: http:// www.guttmacher.org/pubs/AWWfullreport.pdf. [16] Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. [17] Sedgh G, Henshaw S, Singh S, Ahman E, Shah IH. Induced abortion: rates and trends worldwide. Lancet 2007;370(9595):1338–45.
[18] World Health Organization. Safe abortion: technical and policy guidance for health systems. Geneva: WHO; 2003. Available at: http://www.who.int/reproductivehealth/ publications/unsafe_abortion/9241590343/en/index.html. [19] Center for Reproductive Rights. Briefing Paper: Abortion and Human Rights. New York: Center for Reproductive Rights; 2008. Available at: http://reproductiverights.org/sites/ crr.civicactions.net/files/documents/BRB_abortion_hr_revised_3.09_WEB.PDF. [20] United Nations Committee Against Torture. Consideration of Reports Submitted by States Parties Under Article 19 of the Convention. Concluding observations of the Committee against Torture. Nicaragua. Geneva; 2009. Available at: http:// www2.ohchr.org/english/bodies/cat/docs/CAT.C.NIC.CO.1_en.pdf. [21] Hyman A, Kumar A. A woman-centered model for comprehensive abortion care. Int J Gynecol Obstet 2004;86(3):409–10. [22] Mayi-Tsonga S, Oksana L, Ndombi I, Diallo T, de Sousa MH, Faundes A. Delay in the provision of adequate care to women who died from abortion-related complications in the principal maternity hospital of Gabon. Reprod Health Matters 2009;17(34):65–70.
Contents lists available at ScienceDirect
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
PRECONGRESS WORKSHOP
Critical gaps in universal access to reproductive health: Contraception and prevention of unsafe abortion Kelly R. Culwell a,⁎, Marcel Vekemans a, Upeka de Silva a, Manuelle Hurwitz a, Barbara B. Crane b a b
International Planned Parenthood Federation, Central Office, London, UK Ipas, Chapel Hill, NC, USA
a r t i c l e Keywords: Abortion Contraception Human rights Maternal mortality Prevention
i n f o
a b s t r a c t Unsafe abortion accounts for a significant proportion of maternal deaths, yet it is often forgotten in discussions around reducing maternal mortality. Prevention of unsafe abortion starts with prevention of unwanted pregnancies, most effectively through contraception. When unwanted pregnancies occur, provision of safe, legal abortion services can further prevent unsafe abortions. If complications arise from unsafe abortion, emergency treatment must be available. Recommendations made on this issue during the Precongress Workshop held prior to the 2009 FIGO World Congress in Cape Town, South Africa, were part of a report that was adopted by the FIGO General Assembly. These recommendations address prevention of unsafe abortion and its consequences and support access to safe abortion care to the full extent allowed by national laws, along with 6 strategies for implementation, including integration of family planning into other reproductive health services, adequate training for providers, task-sharing with mid-level providers, and using evidence to discuss this issue with key stakeholders. © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Unsafe abortion accounts for 13% of maternal mortality [1] and results annually in nearly 70 000 deaths worldwide; 99% of these occur in low-resource countries (35 600 in Sub-Saharan Africa; 28 400 in Asia; and about 2000 in Latin America, the Caribbean, and Oceania combined) with only a few in high-resource regions of the world (under 60 in Europe and North America combined) [1]. Besides mortality, unsafe abortion can be responsible for temporary or permanent disability, including secondary infertility, in millions of women. As we approach 2015, it has been recognized that Millennium Development Goal (MDG) number 5 (reducing maternal mortality and universal access to reproductive health) has seen the least progress of all of the MDGs [2]. Unfortunately, global initiatives focusing on reducing maternal mortality largely ignore unsafe abortion as a significant cause of maternal mortality and morbidity. Unsafe abortion, along with HIV/sexual and reproductive health linkages and adolescent sexual health, was selected as one of the “critical gaps in universal access to reproductive health” to be addressed during the Precongress Workshop held prior to the XIX FIGO World Congress of Gynecology and Obstetrics in October 2009 in Cape Town, South Africa, sponsored by the WHO/FIGO Alliance on ⁎ Corresponding author. International Planned Parenthood Federation, 4 Newhams Row, London SE1 3UZ, United Kingdom. Tel.: +44 20 7939 8273; fax: +44 20 7939 8300. E-mail address: [email protected] (K.R. Culwell).
Women's Health. The Precongress Workshop brought together over 100 of the world's experts in women's health, approximately 40 of whom chose to address the topic of unsafe abortion. The discussion on unsafe abortion focused on 3 areas: preventing unwanted pregnancies; prevention of unsafe abortion; and managing complications of unsafe abortion to prevent morbidity and mortality. 2. Preventing unwanted pregnancies As nearly all unsafe abortions are a result of unwanted pregnancies, prevention of unwanted pregnancy is a logical best option for reducing the number of unsafe abortions. 2.1. Promoting the use of contraception The right to plan one's family and space one's children is specified in Article 16.1 of the United Nations Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) and was reemphasized in the Programme of Action from the International Conference on Population and Development (Cairo, Egypt, 1994) and the Platform for Action from the Fourth World Conference on Women (Beijing, China, 1995). However, it is currently estimated that 215 million women globally who wish to limit or space their childbearing are not using a modern contraceptive method [3]. This unmet need is greatest among the most vulnerable populations with disproportionately high levels among poor, adolescent, and rural women [3].
0020-7292/$ – see front matter © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2010.04.003
S14
K.R. Culwell et al. / International Journal of Gynecology and Obstetrics 110 (2010) S13–S16
The reasons for unmet need are both supply and demand driven. Governments in many countries have failed to make funding for reproductive health a priority in national budgets. Logistics problems along with funding shortages create a lack of commodities in the areas where they are most needed. The Guttmacher Institute and the United Nations Population Fund (UNFPA) estimate that US $6.7 billion annually is needed to meet current and unmet need for contraceptives globally, a figure more than double that of current global investment in family planning [3]. Healthcare providers themselves often impose unnecessary barriers to provision of contraceptive services [4], including denial of a contraceptive method on the basis of age, parity, marital status, or lack of parental or spousal authorization, which can make it more difficult for a woman to obtain and continue with a contraceptive. Moreover, a limited choice of contraceptive methods and poor contraceptive counseling can result in women being given contraceptive methods that are difficult for them to continue. Ideally, internationally accepted evidence-based protocols such as the WHO Medical Eligibility Criteria [5] and Selected Practice Recommendations [6] should be used to create evidence-based practice guidelines at the country level and assist healthcare providers and program managers in appropriate delivery of family planning methods. Reducing the unmet need for contraceptives and unwanted pregnancies is difficult without attention to comprehensive sexual and reproductive health and rights. When women lack autonomy to make decisions for themselves and their families, their access to uninterrupted family planning services is compromised. Provision of correct information is also crucial to combat the myths and misconceptions held by women, their families, and communities about contraceptive methods. Cultural and religious barriers, including disempowerment of women, particularly the poor and those living in rural areas, leads to lack of awareness of the availability of contraceptive methods and inequitable access to services. The taboo surrounding pre-marital sexual activity among young people often leads to discriminatory laws or attitudes among healthcare providers and clinic staff, which deters young people from being able to access contraceptive services as well as comprehensive sexual and reproductive health care. 2.2. Promoting general and sexuality education Education is an important factor in the prevention of unwanted pregnancy and unsafe abortion. Comprehensive sexuality education encourages, where appropriate, a delay in starting sexual activity and results in a reduction in the number of sexual partners and increased condom or contraceptive use [7]. In contrast, there is no evidence that abstinence-only education has any effect on reducing abortion rates. Young people pledging abstinence until marriage will have sex as soon as non-pledgers, but are less likely to protect themselves from unintended pregnancy or sexually transmitted infections [8,9]. 2.3. Eliminating gender-based violence It is a tragic reality that many unsafe abortions are a result of unwanted pregnancies after forced intercourse or violence, especially for women who are young or in other vulnerable circumstances. Women and girls in conflict situations suffer especially when rape is used as a weapon of war. In a multi-country study conducted by WHO, up to 30% of women in some regions reported that their first experience of sexual intercourse was forced or coerced [10]. In addition, the study found that the younger the girl was at the time of sexual initiation, the more likely she was to report her first sexual intercourse was a result of force or coercion [10]. This is particularly significant to the issue of unsafe abortion, since it is estimated that 40% of unsafe abortions in low-resource countries were in women under the age of 25. That number is nearly 60% in Africa [11].
3. Prevention of unsafe abortion: Replacing unsafe abortion by legal safe abortion According to the FIGO Committee for the Study of Ethical Aspects of Human Reproduction and Women's Health, “Providing the process of properly informed consent has been carried out, a woman's right to autonomy, combined with the need to prevent unsafe abortion, justifies the provision of safe abortion” [12]. Only 40% of the world population can access abortion without restriction as to reason, within gestational limits [13]. Everywhere else laws restrict access to safe abortion to a lesser or greater degree [14]. There has been a trend in recent years toward reduced restrictions within abortion laws globally. Of the 21 countries that have changed their abortion laws since 1997, 19 of those reduced restrictions. On the other hand, a few countries have increased their restrictions, including El Salvador and Nicaragua—both eliminating all legal indications for abortion, even when necessary to save a woman's life [15]. While most countries allow safe abortion for conditions endangering women's lives and health, the definition of health used by the World Health Organization, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [16], is rarely applied when interpreting such laws. It is well understood that legal restrictions do not lower the incidence of abortion; thus the abortion rate of 29 per 1000 women of reproductive age in Africa, where abortion is mostly illegal, is similar to that of 28 per 1000 women in Europe, where abortion is generally permitted on broad grounds [17]. The difference is the high death toll in Africa, where the abortions are predominantly unsafe. The arguments for the provision of safe, legal abortion services include those from a public health, human rights, social justice, and even economic point of view. Even if contraceptives are widely available and used, contraceptive methods are not perfect, nor are users. Therefore, there will always be need for safe abortion services when unwanted pregnancies occur. Abortion, when provided in a safe environment by properly trained providers, is one of the safest medical procedures [18]. Safe, legal abortion is an extremely effective way of eliminating unsafe abortion and the deaths and long-term consequences resulting from it [18]. Preventing these deaths could make a significant impact in countries’ efforts to meet the MDG 5 target of a 75% reduction in the maternal mortality ratio by 2015. Failing to provide access to safe abortion services or prosecuting women for seeking abortion services is increasingly recognized as a violation of a woman's right to life, right to health, right to be free from torture and cruel inhuman degrading treatment and punishment, and the right to non-discrimination [19]. In addition, the UN Committee on Torture has held that forcing a woman to carry a pregnancy to term that was a result of sexual violence entails continued violation of her human rights [20]. However, many countries do not allow legal abortion in the case of rape or incest, and for those that do have legal exceptions for these reasons, access to services for these indications is often limited or non-existent. Not only does unsafe abortion carry a heavy human cost, but it also places a burden on health systems that are already financially stretched. The cost to the government health systems of treating complications from unsafe abortion is several times that of contraceptive and safe abortion services. It is estimated that health systems in developing countries expend US $460–550 million per year (in 2006 dollars) to treat severe consequences of unsafe abortion [15]. As noted above, increasing access to comprehensive abortion care will reduce the practice of unsafe abortion and its consequences. Comprehensive abortion care includes pre- and post-abortion counseling, surgical and (where possible) medical drug-induced techniques, and post-abortion care—both emergency services and post-abortion contraception [21]. Post-abortion contraceptive counseling and services, including availability of highly effective long-acting contraceptives (intrauterine devices and implants) and
K.R. Culwell et al. / International Journal of Gynecology and Obstetrics 110 (2010) S13–S16
sterilization, where appropriate, are essential components of postabortion care. These services should necessarily be both youthfriendly and accessible to hard-to-reach segments of the population. 4. Managing complications of unsafe abortion to prevent morbidity and mortality: Provision of quality post-abortion care The stigma associated with abortion in many countries combined with the restrictive legal environment and criminalization of the woman lead to a lack of compassionate, appropriate care of the consequences of unsafe abortion. A recent study from Gabon looked at the delay in care from the time of presentation to the healthcare facility to initiation of care among women who died from various maternity-related causes [22]. For women who died from postpartum hemorrhage or eclampsia, the delay in treatment was just over 1 hour. However, the delay in initiating care for women who died from unsafe abortion complications was nearly 24 hours from the time of presentation to the health facility. Unfortunately, this is the experience of far too many women in low-resource countries who suffer complications from unsafe abortion. Adolescents, unmarried women, or women with HIV may face double or triple stigmatization of being pregnant outside of marriage or with HIV and then again if they choose to end the pregnancy. When these women—or women who are too poor to access care—experience complications of unsafe abortion, they are far less likely to seek or receive treatment for those complications. It is estimated that of the over 7 million women who have complications of unsafe abortion, nearly 40% do not obtain adequate care [15]. The harmful effects of unsafe abortion can be alleviated through the provision of high-quality and timely post-abortion care. This care includes basic treatments that are common in postpartum care, including uterine evacuation (via vacuum aspiration or misoprostol), antibiotics, analgesics, blood transfusion, and uterotonics such as oxytocin. More severe complications will require secondary or tertiary settings where surgical theatres are available, but most of the early or minor complications can be treated in the primary care facility by a trained, mid-level provider. These services simply need to be available, of high quality, and women need to be aware of them and able to access them with minimal delay. As noted above, however, simply having the services in place will not ensure that all complications of unsafe abortion are treated in a timely manner, unless women feel safe in accessing the services and confident that they will receive non-judgmental care. 5. Recommendations The following recommendations for obstetrician-gynecologists and FIGO member societies were presented to the FIGO General Assembly as part of a full report on the proceedings from the PreCongress Workshop on “Critical Gaps in Universal Access to Reproductive Health.” 1. Ensure access to counseling and services for all effective methods of contraception, including emergency contraception, for all women, with special attention to the needs of those who are young, those at risk of HIV, poor, rural, or in other vulnerable groups. 2. Ensure that women with complications of unsafe abortion receive the same quality of care as all other women, nonjudgmental, with minimum delay, and with attention to their other sexual and reproductive health needs. Post-abortion care is part of emergency obstetric care and should be available in all settings. 3. Ensure access to safe abortion care to the full extent allowed by national laws in accordance with FIGO and WHO guidelines on safe abortion, including clear regulations that protect obstetricians
S15
and gynecologists, other healthcare providers, and the women they serve. 4. Strategies to implement these recommendations include: a. Promote integration of family planning with postpartum, abortion, and post-abortion care, in accordance with WHO guidelines and the joint statement on “Family Planning: a Key Component of Post-abortion Care” by FIGO, the International Confederation of Midwives, the International Council of Nurses, and the United States Agency for International Development. b. Ensure that obstetricians and gynecologists receive adequate pre-service, in-service, and on-the-job training on evidencebased practices and technologies for contraception, abortion care, and counseling, as well as on legal, social, and psychological aspects of women's sexual and reproductive health. c. Support task-sharing through the authorization, training, and supervision of general practitioners, midwives, nurses, and other mid-level providers to provide contraceptive and safe abortion and post-abortion care. d. Ensure that all obstetrician/gynecologists and other healthcare providers receive adequate training and sensitization in human rights principles, including sexual and reproductive rights. e. Provide accurate evidenced-based information and accepted ethical principles as a basis for informed dialogue with other key stakeholders, including policy makers, the media, other professional groups, and the public. f. Strengthen capacities of FIGO member societies to provide leadership in collaboration with other stakeholders in helping women to prevent and manage unwanted pregnancies, including access to safe and legal abortion as allowed by law.
Conflict of interest The authors declare no conflict of interest. References [1] World Health Organization. Unsafe abortion: global and regional estimates of incidence of unsafe abortion and associated mortality in 2003. Geneva: WHO; 2007. Available at: http://www.who.int/reproductivehealth/publications/unsafe_ abortion/9789241596121/en/index.html. [2] Rosenfield A, Maine D, Freedman L. Meeting MDG-5: an impossible dream? Lancet 2006;368(9542):1133–5. [3] Singh S, Darroch JE, Ashford LS, Vlassoff M. Adding it up: The costs and benefits of investing in sexual and reproductive health. New York: Guttmacher Institute and United Nations Population Fund (UNFPA); 2009. [4] Brown SS, Burdette L, Rodriguez P. Looking inward: Provider-based barriers to contraception among teens and young adults. Contraception 2008;78(5):355–7. [5] World Health Organization. Medical eligibility criteria for contraceptive use. 4th ed. Geneva: WHO; 2009. Available at: http://whqlibdoc.who.int/publications/2009/ 9789241563888_eng.pdf. [6] World Health Organization. Selected practice recommendations for contraceptive use. 2nd ed. Geneva: WHO; 2004. Available at: http://www.who.int/reproductivehealth/ publications/family_planning/9241562846index/en/index.html. [7] Kirby D. Emerging answers 2007: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy; 2007. Available at: http:// www.thenationalcampaign.org/EA2007/EA2007_full.pdf. [8] Collins C, Alagiri P, Summers T. Abstinence only vs. comprehensive sex education: What are the arguments? What is the evidence? San Francisco: AIDS Policy Research Center & Center for AIDS Prevention Studies. San Francisco: AIDS Research Institute, University of California; 2002. Available at: http://ari.ucsf.edu/ science/reports/abstinence.pdf. [9] Rosenbaum JE. Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers. Pediatrics 2009;123(1):e110–20. [10] World Health Organization. Multi-country study on women's health and domestic violence against women: initial results on prevalence, health outcomes and women's responses. Geneva: WHO; 2005. Available at: http://www.who.int/ gender/violence/who_multicountry_study/en/index.html. [11] Shah I, Ahman E. Age patterns of unsafe abortion in developing country regions. Reprod Health Matters 2004;12(24 Suppl):9–17. [12] FIGO Committee for the study of Ethical Aspects of Human Reproduction and Women's Health. Ethical Aspects of Induced Abortion for Non-Medical Reasons. Ethical Issues in Obstetrics and Gynecology. London: FIGO; 2009. p. 102–4.
S16
K.R. Culwell et al. / International Journal of Gynecology and Obstetrics 110 (2010) S13–S16
[13] Center for Reproductive Rights. The World's Abortion Laws 2008; 2008. New York, Center for Reproductive Rights. Available at: http://reproductiverights.org/sites/ crr.civicactions.net/files/pub. [14] Vekemans M, de Silva U, Hurwitz M. Access to safe abortion. A tool for assessing legal and other obstacles. London: International Planned Parenthood Federation; 2008. Available at: http://www.ippf.org/NR/rdonlyres/6649ED84-2EA1-4C88-8A86CA19BBB19463/0/AbortionLawToolkit.pdf. [15] Singh S, Wulf D, Hussain R, Bankole A, Sedgh G. Abortion Worldwide: A decade of uneven progress. New York: Guttmacher Institute; 2009. Available at: http:// www.guttmacher.org/pubs/AWWfullreport.pdf. [16] Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. [17] Sedgh G, Henshaw S, Singh S, Ahman E, Shah IH. Induced abortion: rates and trends worldwide. Lancet 2007;370(9595):1338–45.
[18] World Health Organization. Safe abortion: technical and policy guidance for health systems. Geneva: WHO; 2003. Available at: http://www.who.int/reproductivehealth/ publications/unsafe_abortion/9241590343/en/index.html. [19] Center for Reproductive Rights. Briefing Paper: Abortion and Human Rights. New York: Center for Reproductive Rights; 2008. Available at: http://reproductiverights.org/sites/ crr.civicactions.net/files/documents/BRB_abortion_hr_revised_3.09_WEB.PDF. [20] United Nations Committee Against Torture. Consideration of Reports Submitted by States Parties Under Article 19 of the Convention. Concluding observations of the Committee against Torture. Nicaragua. Geneva; 2009. Available at: http:// www2.ohchr.org/english/bodies/cat/docs/CAT.C.NIC.CO.1_en.pdf. [21] Hyman A, Kumar A. A woman-centered model for comprehensive abortion care. Int J Gynecol Obstet 2004;86(3):409–10. [22] Mayi-Tsonga S, Oksana L, Ndombi I, Diallo T, de Sousa MH, Faundes A. Delay in the provision of adequate care to women who died from abortion-related complications in the principal maternity hospital of Gabon. Reprod Health Matters 2009;17(34):65–70.