1. April 30, 2015April 30, 2015April 30, 2015 Unsafe Abortion Mortality: New Estimates and Trends, Health and Social Consequences Presented at the International Interdisciplinary Symposium on Reducing Maternal Mortality in sub-Saharan Africa: better understanding for better action Dakar, Senegal – December 13-16, 2010 1 Professor FE Okonofua University of Benin, Nigeria

2. April 30, 2015April 30, 2015April 30, 2015 Background  The WHO defines Unsafe Abortion as: “A procedure for terminating an unintended pregnancy that is carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both¨  Despite increasing prevalence of contraception and the existence of safe and effective methods of abortion, millions of unsafe abortion continue to take place globally each year resulting in increased risks of associated morbidity and mortality  The objective of this presentation is to provide the most recent WHO estimates of unsafe abortion and to elucidate the associated health and social consequences 2

3. April 30, 2015April 30, 2015April 30, 2015 Methodology  Review of the most recent WHO publications and database on unsafe abortion and associated mortality  Review of other publications relating to trends in abortion incidence and mortality  Recent papers published by Shah and Ahman in Reproductive Health Matters and Susheela Singh in the Lancet 3

4. April 30, 2015April 30, 2015April 30, 2015 Unsafe Abortion in 2008 4  WHO estimates that 21.6 million unsafe abortions took place worldwide in 2008, almost all in developing countries  The best indicators for measuring unsafe abortion are: - Unsafe abortion rate: the number of unsafe abortions per 1000 women aged 15-44 years - Unsafe abortion Ratio: the number of unsafe abortions per 100 live births

5. 5 Estimated Annual Incidence of Unsafe Abortion per 1000 Women Aged 15-44 years, by UN Sub- region, 2008 Number of Unsafe Abortions (rounded) Unsafe Abortion Rate (per 1000 women aged 15-44 years) Unsafe Abortion Ratio (per 100 live births) World21,600,0001416 More developed regions*360,00013 Less developed regions21,200,0001617 Least developed countries5,020,0002718 Sub-Saharan Africa5,510,0003117 Africa6,190,0002817 Eastern Africa2,430,0003620 Middle Africa930,0003618 Northern Africa900,00018 Southern Africa120,000910

6. April 30, 2015April 30, 2015April 30, 2015 Contd 6 Western Africa1,810,0002816 Asia*10,810,0001214 Eastern Asia*°°° South-Central Asia6,850,00017 South-eastern Asia3,130,0002228 Western Asia830,00016 Europe360,00025 Eastern Europe360,000512 Northern Europe°°° Southern Europe°°° Western Europe°°° Latin America and the Caribbean4,230,0003139 Caribbean170,0001822 Central America1,070,0002934 South America2,990,0003243 Northern America°°° Oceania*18,00087 Australia/New Zealand°°°

7. April 30, 2015April 30, 2015April 30, 2015 Estimated Annual Number of Unsafe Abortions, Rates and Ratios, By Geographical Regions, 2008 7

8. April 30, 2015April 30, 2015April 30, 2015 Unsafe Abortion Rates Per 1000 Women of Ages 15-44 For All Countries 8

9. April 30, 2015April 30, 2015April 30, 2015 Estimated Number of Unsafe Abortion Globally and by Major Regions, 2003 and 2008 9

10. April 30, 2015April 30, 2015April 30, 2015 Unsafe Abortion Rates Per 1,000 women 10

11. April 30, 2015April 30, 2015April 30, 2015 Consequences of Unsafe Abortion  Despite being a simple procedure, one in four women having an unsafe abortion face the risk of severe complications  Worldwide, unsafe abortion account for 13% of maternal deaths, and 20% of overall burden of maternal death and longer term disability as measured in Disability Adjusted Life-Years (DALYs)  Compared with developed countries the burden per 1000 unsafe abortions is more than six times as high in sub- Saharan Africa and four times as high in Asia 11

12. April 30, 2015April 30, 2015April 30, 2015 Consequences of Unsafe Abortion  Unsafe abortions accounted for 20,500 maternal deaths in 2005  Among the estimated 358,000 global maternal deaths in 2008, 47,000 were due to complications of unsafe abortion (nearly a doubling)  Over half of these were in Africa, while 34% occurred in the least developed countries  MMR associated with abortion was 650 deaths per 100,000 unsafe in 2003, compared to 10 per 100,000 in developed countries 12

13. April 30, 2015April 30, 2015April 30, 2015 36% The World’s Population Live Where Abortion is Very Restricted 13

14. April 30, 2015April 30, 2015April 30, 2015 Restricting Contraception and Legal Abortion In Romania Resulted In Increased Maternal And Abortion- related Deaths 14

15. April 30, 2015April 30, 2015April 30, 2015 Distribution of Countries by Number of Deaths due to Unsafe Abortion 15 Number of deaths per 100 000 live births

16. April 30, 2015April 30, 2015April 30, 2015 Distribution of Countries By Number of Deaths Due to Unsafe Abortion 16 Region and Sub-region Number of maternal deaths due to unsafe abortion (rounded) Deaths due to unsafe abortion (as % of all maternal deaths) Deaths due to unsafe abortion per 100,000 live births (rounded) World70 5001355 More developed<604. Less developed Countries 70 4001360 Least developed countries 24 0001085 Less developed regions, excluding China 70 4001370 Africa38 40014115 Eastern14 80017130 Middle660011130 Northern12001125 Southern500940 Western15 30013140

17. April 30, 2015April 30, 2015April 30, 2015 Estimates of Deaths due to Unsafe Abortion in 2005 in three countries 17 Annual number of women treated in hospital for induced abortion complications Annual hospitalization rate for induced abortion complications per 1000 women Egypt 216 00015.3 Nigeria 142 2006.1 Uganda 85 00016.4

18. April 30, 2015April 30, 2015April 30, 2015 Health Consequences Are Often Severe And Can Be Long-term  Kenya: 28% of post-abortion patients experienced severe complications  Nigeria: among hospitalized patients, one in 3 had hemorrhage, one in four sepsis and about 1 in 10 had injury to other organs  Abortion in the second trimester greatly increases risk  There are many long-term consequences

19. April 30, 2015April 30, 2015April 30, 2015 Additional Consequences  Loss of productivity  Increased economic burden and cost to the public health system  Social & cultural stigma  Long term ill-health, including infertility  Overall, some 24 million women are estimated to be currently suffering from secondary infertility due to unsafe abortion 19

20. April 30, 2015April 30, 2015April 30, 2015 Contraception is Key to Prevention Of Unsafe Abortion  It is well documented that family planning programs reduce abortion  There can be a lag: the desire for small families may increase faster than contraceptive use  But contraception does not eliminate the need for safe abortion, and there are several other reasons why women result to abortion  Governments and stakeholders must improve access to contraceptive information and services

21. April 30, 2015April 30, 2015April 30, 2015 Prevention of Unsafe Abortion Includes More than Contraception  Access to safe and legal abortion is the most fundamental means of prevention  Also important are use of safer techniques and training of providers in these techniques  Manual vacuum aspiration is effective and suitable for low resource settings  Early medication abortion is a new and recommended technique

22. April 30, 2015April 30, 2015April 30, 2015 Prompt And Appropriate Treatment Of Complications Is Also Important  WHO has issued guidelines for provision of safe abortion care & treatment of complications  Post abortion contraceptive counseling and services are essential  Rapid transfer to tertiary care can be lifesaving

23. April 30, 2015April 30, 2015April 30, 2015 The Public Health Imperative  The rationale for making safe abortion available is well established  The public health record is clear and incontrovertible: access to safe, legal abortion improves health  Cairo, 1994:”In circumstances where abortion is not against the law, such abortion should be safe.”

24. April 30, 2015April 30, 2015April 30, 2015 Dealing with Unsafe Abortion in Africa The Maputo Plan of Action  Enact policies and laws to reduce the incidence of unsafe abortion  Prepare and implement national POA to reduce the incidence of unwanted pregnancies & unsafe abortion  Provide safe abortion services to the fullest extent of the law  Educate communities on available safe abortion services as allowed by natural laws  Train health providers in prevention and management of unsafe abortion 24

25. April 30, 2015April 30, 2015April 30, 2015 Mahmoud Fathalla Sums Up The Situation Very Well “ Pregnancy-related deaths are often the ultimate tragic outcome of the cumulative denial of women’s human rights. Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.” Simply put, they die because they do not count.

26. April 30, 2015April 30, 2015April 30, 2015 Some References:  Shah H, Ahman E. Unsafe abortion: global and regional incidence, trends, consequences and challenges. J Obstet Gynecol Can 2008; 31: 1149-1158.  Singh S. Hospital Admissions resulting from unsafe abortion: estimates from 13 developing countries. Lancet 2006; 368: 1887-1892.  Grimes D, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, Shah IH. Unsafe abortion: A preventable pandemic. Lancet 2006 (Special Edition): 65-76.  Sedgh G, Henshaw S, Singh S, Ahman E, Shah IH. Induced abortion: estimated rates and trends worldwide. Lancet 2007, 370, 1338-1345 26

27. April 30, 2015April 30, 2015April 30, 2015 Acknowledgements  Dr Alain Prual of UNFPA, and Dr Brooke Levandowski of Ipas, USA For sharing some of the reading materials with me. 27

28. April 30, 2015April 30, 2015April 30, 2015 Thank you Merci 28