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Abortion Worldwide: A Decade of Uneven Progress

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1 Abortion Worldwide: A Decade of Uneven Progress
Guttmacher Institute © October 2009

2 What’s new Trends in contraceptive use, unmet need for contraception and unintended pregnancy rates Changes in the legal status of abortion More comprehensive look at abortion and women’s lives Abortion Worldwide: A Decade of Uneven Progress provides new data and analysis, including the companion regional summaries for Asia, Latin America and the Caribbean and Sub-Saharan Africa. It presents for the first time trends in contraceptive use, unmet need for contraception and unintended pregnancy. It documents significant legal changes over the past decade. And it offers greater context around the issue of abortion. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009.

3 Most trends are positive
Worldwide decline in abortion incidence Global rise in contraceptive use Decline in unintended pregnancy Liberalized abortion laws in a number of countries Growing access to abortion, even in legally restrictive countries Significant global changes have occurred in the past decade in both developed and developing countries. Increases in global contraceptive use have contributed to a decrease in unintended pregnancies and in turn a decline in the number of abortions, which fell from an estimated 45.5 million in 1995 to 41.6 million in 2003. These positive trends have occurred simultaneously with a global trend towards liberalizing abortion laws. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009.

4 Abortion has declined worldwide
Abortions per 1,000 women aged 15–44 39 35 34 29 29 26 In every major region of the world, abortion is on the decline. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009. World More developed countries Less developed countries 4

5 Unintended pregnancy rates are down in the developing world
Unintended pregnancies per 1,000 women aged 15–44 Unintended pregnancy has declined at least slightly in all major developing regions since 1995, progress that can at least in part be attributed to greater access to contraception. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009. *Excludes Eastern Asia

6 Contraceptive use is on the rise
Around the world, more women are using contraception. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009.

7 Safe abortion is more available
19 countries (including the Mexican Federal District) have liberalized their laws Availability of medication abortion has improved Use of manual vacuum aspiration has increased Nineteen countries have liberalized their laws since 1997. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009.

8 But progress has been uneven
Levels of unsafe abortion have not declined Unmet need for contraception remains high in some regions Many women lack access to safe abortion Abortion-related mortality and morbidity remain higher The poor bear the greatest burden Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009.

9 Unsafe abortion rates have not changed
Abortions per 1,000 women aged 15–44 39 35 34 29 29 26 The overall rate of abortion declined between 1995 and 2003, the rate of unsafe abortion hardly changed. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009. World More developed countries Less developed countries

10 40% of women worldwide live under highly restrictive abortion laws
Legal Grounds Forty percent of women worldwide live in countries where abortion is prohibited altogether or legal only to protect a woman’s life or physical health. Almost all of these are in developing countries. Access remains extremely limited in Sub-Saharan Africa and Latin America in particular. In Africa, 92% of women of reproductive age live under severely restrictive abortion laws, in Latin America 97% do so. The remaining 60% of the world’s women live in countries where the procedure is broadly legal. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009. 1.55 billion women aged 15–44, 2008 10

11 Unmet need for contraception is still high…
Latin America & Caribbean 1990–1995 2002–2007 Asia 1990–1995 2002–2007 The unmet need for contraception is an important factor contributing to unsafe abortion. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009. 1990–1995 Africa 2002–2007 Married women aged 15–44

12 Leading to high rates of unintended pregnancy
Modern method No method Traditional method Behind virtually every abortion is an unintended pregnancy. In developing countries, two-thirds of unintended pregnancies occur to women who were not using any family planning method at the time of conception. Another 14% occurred to the relatively small proportion of women using a traditional method. Source: Singh et al., Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care, New York: The Alan Guttmacher Institute and United Nations Population Fund, 2003. Unintended pregnancies in developing countries, by women’s contraceptive use 12

13 All pregnancies in developing countries
More than one-third of pregnancies in developing countries are unintended More than one-third of pregnancies in developing countries—about 76 million each year—are unintended. About half of these end in induced abortions, most of which are either illegal or unsafe. Source: Singh et al., Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care, New York: The Alan Guttmacher Institute and United Nations Population Fund, 2003. All pregnancies in developing countries 13

14 Almost all unsafe abortions occur in the developing world
42 7 Of the almost 42 million abortions worldwide in 2003, about half were unsafe. That is to say, nearly 21 million abortions were carried out under unhygienic conditions, by individuals who were inadequately trained, or were self induced, often using a range of primitive methods. Virtually all of these 20 million unsafe abortions occurred in the developing countries. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009. 35 Millions of abortions, 2003

15 Nearly all abortions in Africa and Latin America are unsafe
Almost all abortions –in Africa, and Latin America and the Caribbean are unsafe. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009.

16 19.2 million unsafe abortions
Four in 10 women having unsafe abortions experience complications requiring treatment We estimate that about four in 10 of all women who have abortions in developing countries experience a complication that is serious enough to require treatment in a health facility. A substantial proportion of these women do not obtain the care they need. Out of about eight million who have such complications, about 5 million require costly treatments, while another three million do not obtain care at all. Other Guttmacher studies in Guatemala and Uganda (2006), show that the stigma associated with abortion contributes to many women delaying efforts to seek medical care, resulting in worse outcomes. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009. 19.2 million unsafe abortions

17 In countries with restrictive abortion laws, providers of abortion are often untrained
% of women having abortions 100 80 60 40 Studies in developing countries with restrictive abortion laws help us to understand who provides clandestine abortions. As this figure shows, large proportions of women who obtain abortions do so from providers who lack formal training, and a small but significant group attempt to induce the abortion themselves. Studies in these countries also show that even among procedures provided by formally trained health officials, a substantial proportion result in complications that are serious enough to require treatment. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009. 20

18 Poor women are most likely to experience serious abortion complications
Of women having abortions, % experiencing serious complications Studies make clear that poor women are much more likely to experience serious complications from unsafe abortion than better off women, mostly because they are less able to pay for the services of formerly trained health professionals. Similarly large differences are found between rural and urban women. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009.

19 Health consequences are often severe and long-term
Kenya: 28% of abortion complications among women seeking treatment were severe Nigeria: Among hospitalized patients: 1 in 3 had hemorrhage 1 in 4 had sepsis 1 in 10 suffered other injuries Second trimester abortion greatly increases risk Many women experience long-term consequences Abortion complications are often severe. In Kenya, for example, 28% suffered severe complications – generalized infection, high temperature, injury, organ or system failure, shock or death. The situation is similar in Nigeria. Unsafe abortions occurring in the second trimester of pregnancy are much more likely to have severe complications. Yet one-third of women hospitalized for post abortion care in Kenya and one-fifth in Nigeria were in the second trimester. Many women experience long-term and in some cases life-long consequences, including infertility. Sources: Gebreselassie H et al., The magnitude of abortion complications in Kenya, BJOG, 2005, 112(9):1229–1235 and Henshaw SK et al., Severity and cost of unsafe abortion complications treated in Nigerian hospitals, International Family Planning Perspectives, 2008, 34(1):40–50. 19

20 Costs of unsafe abortion to women, their families and society are large
Postabortion care costs Africa and Latin America nearly $300 million annually An estimated 220,000 children are left motherless every year from abortion-related deaths Loss of productivity affects household functioning It is very difficult to measure the indirect costs of unsafe abortion, and information is limited. However, it is clear that these costs are large. Estimates show that the cost of post abortion care, borne by health systems and families, is about $300m each year in Africa and Latin America combined. An estimated 220,000 children are left motherless each year when women die from unsafe abortion These deaths, and the much larger number of women who suffer abortion complications, impact the economic and overall well-being of their households and more generally affect the community and the country as a whole. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009. 20

21 Unsafe abortion accounts for one in eight maternal deaths
Maternal deaths per 100,000 live births Unsafe abortion is responsible for about 70,000 deaths each year, which is almost one in seven of all maternal deaths. As this slide shows, if you look at the grey portions of each bar, unsafe abortion is a bigger factor in Africa (that’s the tallest bar) than in the other two major developing regions and is estimated to total 36,000 per year, a steadily mounting maternal death toll that affects hundreds of thousands of African families It is also responsible for about 20% of the all years of healthy life that are lost due to pregnancy and childbirth, or what are called disability-adjusted life years (DALYs). Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009.

22 Safe abortion saves lives: South Africa
Between 1994 and 2000, severity of abortion- related complications dropped: Fewer postabortion infections Largest gains by young women Deaths due to unsafe abortion declined by at least 50% Changing the abortion law to permit the procedure under broader legal criteria is an essential step towards preventing unsafe abortions. It must be accompanied by improved access to legal and safe abortion. When this happens, as has occurred in South Africa following the 1996 Law Reform, very positive benefits are achieved relatively quickly. In a six year window South Africa saw a 50% decline in deaths due to unsafe abortion. Source: Jewkes R and Rees H, Dramatic decline in abortion mortality due to the Choice on Termination of Pregnancy Act, South African Medical Journal, 2005, 95(4):250. 22

23 Preventing unintended pregnancy is cost-effective
Estimated $19 million spent annually in treating unsafe abortion complications in Nigeria It would cost only $4.8 million to provide the contraceptive services needed to prevent the pregnancies resulting in these abortions This is a cost-benefit ratio of about 4:1 Treatment of abortion complications is a great burden on the public health system in developing countries. Direct costs include costs of health personnel, medications, blood, supplies and equipment, and overnight hospital stays. One recent study found that an estimated $19 million are spent annually in Nigeria in treating unsafe abortion complications, and that it would cost only $4.8 million to prevent those unintended pregnancies, a cost-benefit ratio of four to one. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009. 23

24 Increased contraceptive use leads to fewer abortions
The worldwide decline in abortion over the past decade has been accompanied by: A worldwide decline in unintended pregnancy A global increase in the proportion of women using contraception The global rate of unintended pregnancy declined from 69 per 1000 women aged in 1995 to 55 per 1000 in The decline was greatest in the developing world. Globally, the proportion of married women practicing contraception increased from 54% in 1990 to 63% in Contraceptive use also increased among unmarried sexually active young women in many developing countries. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009. 24

25 Key interventions to reduce unsafe abortion and its consequences
Expand access to modern contraceptives and improve family planning services Expand access to legal abortion and ensure that safe services are available to women in need Improve the quality and coverage of postabortion care, which would reduce maternal death and disability due to unsafe abortion We know how to reduce the prevalence of unsafe abortion and the death and injury it causes. Three key interventions are preventing unintended pregnancies through better access to contraception and expanding family planning services; expanding access to safe abortion through legal reform; and providing better treatment for women who suffer the complications of unsafe procedures by improving the quality and coverage of postabortion care―including expansion of the safest and most cost effective methods: MVA and medication abortion Concerted efforts by many organizations on all three of these fronts are needed. All three are equally important if unsafe abortion and its consequences are to be reduced, and unintended pregnancy to be prevented. The challenges are great. Legal reform can take many years, impediments include the persistence of outmoded laws, religious opposition, the activities of well-funded anti-choice groups, and reluctance to publicly address sensitive issues. Other barriers include governmental red tape and bureaucracy that often make it difficult to effectively implement new programs and policies. Even when laws are passed to expand access, the overall healthcare system may not be in place to implement these changes. Funding for health services, including contraceptive services and treatment for the complications of unsafe abortion is often lacking. Source: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009.

26 For more information visit Guttmacher.org


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