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Abortion occurs commonly, yet it is stigmatized and hidden. This presentation describes the problems associated with unsafe abortion both globally and in Africa, and outlines strategies to address these problems.
I will begin by sharing information about abortion and unsafe abortion, and the international agreements that deal with this issue. Then, I will discuss how to offer safe abortion services—specifically focusing on clinical issues, how to organise services, and policy barriers. Recommendations here are based primarily on the World Health Organization’s 2003 publication: Safe Abortion: Technical and Policy Guidance for Health Systems.
You should feel free to customise the presentation, selecting modules or slides to best fit the purpose of the presentation and the interests of the audience. Some suggested versions of the slide presentation are available in the User’s Guide, which is included on this CD-ROM. The User’s Guide provides suggestions on which slides to select for health care providers, policymakers, advocates, and media.
This is also an appropriate time to inform your audience of rules for the presentation, such as whether questions should be asked at any time or saved until the end of the presentation.
This presentation contains six modules, covering:
Context and general information on unsafe abortion
Overcoming barriers to access
In African countries, there is a range of laws and practices regarding abortion. In many parts of Africa, women experiencing an unwanted pregnancy face great difficulty in obtaining safe, high-quality abortion services and must seek abortions performed in clandestine, and often unsafe, conditions.
While we don’t have very precise statistics about the impact of unsafe abortion on women and families in Africa, we know that Africa has the highest rate of abortion-related deaths of any region. The World Health Organization (WHO) estimates that 4.2 million unsafe abortions take place in Africa each year. Consequently, about 80 women die from unsafe abortions every day and nearly 30,000 die every year. Unsafe abortion accounts for 12% of all deaths from complications of pregnancy and childbirth in the region. 
However, these WHO estimates may be low. One comprehensive study conducted in Nigeria calculated that there are up to 610,000 abortions each year in that country alone, resulting in 20,000 deaths. Because of the stigma around abortion and its legal restriction in many countries of the region, most services are not documented and it is difficult to obtain accurate estimates of the true number of abortions. 
Of the 46 million abortions that are estimated to take place annually around the world, at least 19 million are unsafe. Nearly 68,000 women die every year from complications related to unsafe abortion throughout the world, accounting for 13% of all maternal deaths .
Customising this slide:
You can customise this slide (or add an additional slide) with facts such as:
Abortion and unsafe abortion rates in your country
Anecdotal information on unsafe abortion in your country
Percentage of women in main ob/gyn hospitals admitted for abortion-related complications
National percentages of how many maternal deaths are attributable to unsafe abortion
1. World Health Organization, Unsafe abortion: Global and regional estimates of incidence of unsafe abortion and associated mortality in 2000, 4th Ed. (Geneva: WHO, 2004), available at: http://www.who.int/reproductive-health/publications/unsafe_abortion_estimates_04/index.html
2. Henshaw, S., et. al, “The incidence of induced abortion in Nigeria,” International Family Planning Perspectives 24 (December 1998).
Regardless of legal status or other factors, abortions take place worldwide. The injustice is that almost all unsafe abortions take place in developing countries (and countries “in transition,” such as those in Eastern Europe and the former Soviet republics). Indeed, almost no unsafe abortions take place in developed countries, where safe abortion is generally more available under the law.  There is no “typical abortion seeker”—abortions occur in all age groups, and a wide range of women, married and unmarried, with and without children, seek abortions.
There is essentially no deaths from abortion where abortion is legal and safe. Legal abortion is safe abortion: In the US, mortality from abortion is .6/100,000 procedures, making it as safe or safe than an injection of penicillin.
Abortions occur in all age groups:
“[Based on studies from 56 countries] the highest proportion of abortions occurs among women aged 20-24 and 25-29.” . However, this pattern reflects in large part lower fertility rates among younger and older women. When those younger and older women do get pregnant, they are more likely to seek abortions, and therefore have a higher ratio of abortion per pregnancy, although a lower rate of abortion overall.
Both married and unmarried women, with and without children, may seek abortion.
A diverse range of women seek abortions; generally, the profile tends to vary by region, and depends on a number of factors, including average age of marriage, prevalence of pre-marital sexual activity, access to contraception, preferred family size, and so on. There are many reasons why a married woman might want to terminate a pregnancy (see next slide) .
Abortion Rate: The number of abortions out of a total number of women of reproductive age.
Abortion Ratio: The number of abortions out of a total number of pregnancies.
Customising this slide:
Use local studies to illustrate the situation in your country. Often, audiences have preconceived ideas about who is affected by abortion (such as primarily adolescents or unmarried women), so it can be useful to demonstrate that a wide range of women have abortions.
1. World Health Organization, Safe Abortion: Technical and Policy Guidance for Health Systems (Geneva: WHO, 2003), available at:http://www.who.int/reproductive-health/publications/safe_abortion/Safe_Abortion.pdf.
2. Bankole, A., S. Singh and T. Haas, “Characteristics of Women Who Obtain Induced Abortion: A Worldwide Review,” International Family Planning Perspectives 25 (June 1999), available at:http://www.agi-usa.org/pubs/journals/2506899.html.
Women may wish to terminate wanted and unwanted pregnancies. For example, even when a woman wants a child, she may feel the need to end the pregnancy because it may threaten her health or survival; or the foetus may have an abnormality. Or, she may feel pressured by shame, stigma, disapproval from her partner, family or community, or even government policies.
Pregnancy may not be supported by the woman’s family or community.
Certain women—such as those who are young, old, unmarried, in school, and/or with many children already—may find that their parents, community members, religious institutions, and even their partners do not approve of their pregnancies. In these circumstances, they may feel pressured to end the pregnancy.
Pregnancy may threaten the woman’s health or survival.
For instance, she may have a health condition such as diabetes, malaria, renal problems, or some types of heart disease, that could be made worse by carrying the pregnancy to term.
Customising this slide:
This slide can be customised according to the situation in your country or region.
Many women do not want to get pregnant, for a wide range of reasons. Yet, millions of unplanned pregnancies occur each year, because:
women do not have access to or use contraception. This may be because of lack of supplies, poor information, and other factors.
contraceptive methods sometimes fail, even when they are used correctly.
many women experience forced or coerced sex which results in pregnancy.
Adolescents are particularly vulnerable to unwanted pregnancy because they tend to have less information about sexuality and contraception, less access to services, and fewer resources to manage their health care. [1, 2]
120-150 million women worldwide want to delay or limit childbirth but do not use contraception. This figure comes from Demographic and Health Surveys and reflects those women (in union or married) who state that they either want no more children or want to delay having their next child, but are not using a method of family planning (that is, they have an “unmet need for family planning”). They may not be using family planning for a variety of reasons, such as:
A lack of access to family planning services. More than 350 million women around the world do not have access to family planning services.
Beliefs that contraceptive methods are unsafe or unsuitable for them
The cost of family planning; or
Opposition to family planning from their husbands or other family members, among other factors. 
“In the majority of African and Middle Eastern countries studied and in a large number of countries in Asia, Latin America, and the Caribbean, at least 20 percent of married women of reproductive age had an unmet need for contraception. The countries with the highest percentage of women with unmet need are in Sub-Saharan Africa: Rwanda (37 percent), Malawi (36 percent), and Kenya (36 percent).” 
Contraceptive methods fail. It is estimated that, globally, over 26 million pregnancies occur to couples using contraception each year. 
Many women experience forced or coerced sex. Representative data are hard to come by, but it is clear from numerous small studies in countries around the world that rape and sexual coercion are all too common. Most victims already know the person attacking or coercing them. Some estimates suggest that as many as one in four women will experience sexual violence at the hands of an intimate partner during her lifetime. Rape is also common in situations of war or ethnic unrest. 
Definitions of Unwanted Pregnancy by Marital Status:
A study in Kenya found that community members defined unwanted pregnancy in a number of ways:
Unmarried Woman: Pregnancy of a single girl; Pregnancy of a young girl; Pregnancy resulting from rape; Pregnancy resulting from incest; Pregnancy that is unplanned; Pregnancy to a woman abandoned by her boyfriend; Pregnancy of a commercial sex worker; Pregnancy with an HIV/AIDS infected male partner; Pregnancy resulting from contraceptive failure (including traditional methods).
Married woman: Pregnancy due to marital rape; Pregnancy too closely spaced; Pregnancy resulting from contraceptive failure; Pregnancy in the midst of too many children; Pregnancy to a poor woman; Pregnancy of an elderly woman; Pregnancy with an irresponsible and/or uncaring husband; Pregnancy of a widow or separated woman; Pregnancy from an extra-marital affair.
Either marital status: Inter-racial pregnancy; Pregnancy to a mentally ill or developmentally disabled woman. 
Customising this slide:
This slide can be customised according to the situation in your country or region by adding DHS data on fertility, preferred family size, and unmet need.  You can also include/discuss unique circumstances contributing to abortion-seeking, such as strong bias towards boy children, etc.
1. Johns Hopkins University Center for Communications Programs, “Meeting Unmet Need: New Strategies,” Population Reports XXIV/1 available at http://www.infoforhealth.org/pr/j43edsum.shtml.
2. RAND Corporation, The Unmet Need for Contraception in Developing Countries, Population Matters Policy Brief (Santa Monica, CA: Rand, 1998), available at http://www.rand.org/publications/RB/RB5024/.
3. World Health Organization, Safe Abortion: Technical and Policy Guidance for Health Systems (Geneva: WHO, 2003), available at: http://www.who.int/reproductive-health/publications/safe_abortion/Safe_Abortion.pdf.
4. World Health Organization, The World Report on Violence and Health (Geneva: WHO, 2002), available at http://www.who.int/violence_injury_prevention/violence/world_report/en/.
5. Rogo, K., L. Bohmer and C. Ombaka, Community level dynamics of unsafe abortion in Western Kenya and opportunities for prevention (Los Angeles, CA: Pacific Institute for Women’s Health, 1999).
6. DHS reports are available online at www.measuredhs.com; you can also order hard copies of DHS reports from the web site or from MEASURE DHS+, Macro International Inc., 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA.7
Many people believe that if abortion is made more available, more abortions will take place. If we look at countries around the world, however, we see that this is generally not the case. Abortion rates are much more likely to be linked to desired family size and availability and effectiveness of contraception. In fact, many countries with restrictive abortion laws also have high abortion rates.
The legal status of abortion, however, does affect the safety of abortion. In countries where abortion is legal and available, it is more likely to be safe, and deaths and disabilities from abortion have been shown to decrease dramatically. There are, however, several countries where abortion is legal but safe services are not widely available because of a lack of training, equipment, awareness of the law, or political will. And, in almost all countries with restrictions on abortion, services are unavailable even for legal indications, such as rape.
The legal status of abortion has little or no impact on rates of abortion
For example, in countries where abortion is legal, the abortion rate varies from 6.5 per 1,000 women (Netherlands) to 8.6 (Tunisia) to 83 (Vietnam). (The rate of abortion is the number of women of reproductive age who have an abortion in one year, out of 1,000 women of reproductive age.) 
In most of the 25 countries that liberalized their abortion laws between 1975 and 1996, the abortion rate increased immediately after legalization, partly because statistics now reflected the true number of abortions, and partly because of increased demand for safe abortions. Abortion rates usually then decreased as contraceptive use increases over time. Generally, where couples used contraception effectively, abortion declined to moderate levels. Where contraceptive use was not widely practiced but there was strong motivation for small families, abortion levels sometimes increased for some time after liberalization. 
The legal status does affect the safety of abortion; where abortion is legal, deaths and disability from abortion are greatly reduced.
In Romania, abortion was legalized in December 1989. In 1990, the number of maternal deaths due to abortion dropped abruptly by more than half. 
Unsafe abortion is the termination of a pregnancy carried out by someone without the skills or training to perform the procedure safely, or in a place that does not meet minimal medical standards, or both. (According to WHO, and endorsed by the UN)
Alan Guttmacher Institute, Sharing Responsibility: Women, Society and Abortion Worldwide (New York: AGI, 1999).
This graph shows that most of the countries with low maternal mortality—the column on the left—permit abortion for non-medical reasons. Of the 37 countries with the highest maternal mortality ratio, only one allows abortion for non-medical reasons. 
1. McKay, H.E., K.O. Rogo and D.B. Dixon, “FIGO society survey: acceptance and use of new ethical guidelines regarding induced abortion for non-medical reasons,” International Journal of Gynecology and Obstetrics 75 (2001): 327-336.
Deaths from unsafe abortion are preventable. When abortions are performed in sanitary conditions by skilled providers, abortion is one of the safest medical procedures in the world.
In fact, safe abortion, both manual vacuum aspiration and medical abortion, is much safer than childbirth.
In contrast, the risk of death following complications of unsafe abortion procedures is several hundred times higher than that of an abortion performed professionally under safe conditions. 
1. World Health Organization, Safe Abortion: Technical and Policy Guidance for Health Systems (Geneva: WHO, 2003), available at: http://www.who.int/reproductive-health/publications/safe_abortion/Safe_Abortion.pdf.
Unsafe abortion has other negative effects on women. For instance, unsafe abortion can result in significant short- and long-term illness and injury. For every death resulting from unsafe abortion, there are countless women who live with pain, infection, and possible infertility.
The costs of treating the complications from unsafe abortion are enormous. In some countries as many as two out of three maternity beds in large urban public hospitals are occupied by women hospitalized for treatment of abortion complications, and as much as one-half of obstetric care budgets is spent treating abortion complications.  2012 Uganda study: Post-abortion care is estimated to cost nearly US$14 million annually in
Uganda... “The epidemic of unsafe abortion takes a tragic toll on women and their families. It poses a significant, avoidable economic burden on
Uganda's already underfinanced health system.”
Injuries and deaths caused by unsafe abortion harm more than just women—they have numerous ill-effects on families, children and communities. For example, a study of maternal mortality in Bangladesh found that children whose mother had died were between three and 10 times more likely than other children to die in the next two years, and a study of HIV-related mortality in Tanzania found that in households where an adult woman had died, children were half as likely to attend school .
Other impacts of injuries and deaths from unsafe abortion on families:
Higher likelihood of malnutrition, illness, and death among children whose mother has died.
Curtailing of educational opportunities for children in families with high medical expenses.
Diminished capacity of the mother to contribute to household income. 
Customising this slide:
You can customise this slide (or add an additional slide) with facts such as:
Abortion and unsafe abortion rates in your country or region
Anecdotal information about unsafe abortion in your country or region
Percentage of women in main ob/gyn hospital admitted for abortion complications, etc.
Regional percentages of maternal deaths attributable to abortion
You may wish to ask your audience for suggestions of negative impacts.
1. Alan Guttmacher Institute, Sharing Responsibility: Women, Society and Abortion Worldwide (New York: AGI, 1999).
2. Inter-Agency Working Group on Safe Motherhood, Safe Motherhood Fact Sheets (New York: FCI, 1998), available at www.safemotherhood.org.
Numerous international agreements have called for improvements in abortion access and care. These international agreements recognise that:
Unsafe abortion is a major public health concern.
Abortion should be safe and available to the full extent of the law.
Health systems have a responsibility to provide these services.
Important international agreements include the Programme of Action of the International Conference on Population and Development (ICPD) and ICPD+5. Statements by international federations such as the International Federation of Gynecology and Obstetrics (FIGO) are also useful tools to advocate for improved access to safe abortion services.
You may wish to provide your audience with handouts containing the text of the relevant agreements, listed below and on the next three slides.
International Federation of Gynecology and Obstetrics (FIGO) Ethics Statement:
“In summary, the Committee recommended that after appropriate counseling, a woman had the right to have access to medical or surgical induced abortion, and that the health care services had an obligation to provide such services as safely as possible.” 
1. International Federation of Gynecology and Obstetrics (FIGO), Guidelines produced by the FIGO Committee for the Study of Ethical Aspects of Human Reproduction and Women’s Health (London: FIGO, 2000), available at http://www.figo.org/default.asp?id=6001.
More recently, the African Union has adopted a protocol to the African Charter on Human and People’s Rights that calls for states to “protect the reproductive rights of women by authorizing medical abortion in cases of sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the unborn child.”  This is the first time abortion has been specifically mentioned in an international treaty.
It comes into force after being ratified by 15 countries and has been ratified by at least 22 countries. It is now important tool for advocating for a wide range of rights for women.
As a result of all of these international agreements, it is clear that every country in Africa has an obligation to ensure that abortion is safe and accessible to the full extent of the law.
1. Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa, adopted July 11, 2003 (Maputo, Mozambique: African Union, 2003).
In 1994, at the International Conference on Population and Development in Cairo, governments recognized that abortion was an important women’s health issue, stated that it should be safe where legal, and called for postabortion care to treat the complications of abortion in all settings.
Programme of Action of the International Conference on Population and Development (ICPD PoA), Paragraph 8.25:
“In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women's health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family-planning services. Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. Post-abortion counselling, education and family-planning services should be offered promptly, which will also help to avoid repeat abortions.” 
1. Programme of Action of the International Conference on Population and Development, Cairo, 5-13 September, 1994 (New York: United Nations, 1994).
In 1999 at the five-year review of the Programme of Action of the International Conference on Population and Development, at a Special Session of the UN General Assembly, governments reiterated the language of Paragraph 8.25, and pledged to “train and equip health-service providers and take other measures to ensure that [legal] abortion is safe and accessible.” In 2004, the Dakar Declaration from the regional review of ICPD implementation in Africa reiterated these commitments. A civil society event held in August 2004 to mark ICPD+10 also reiterated the Cairo commitments and noted that WHO’s Technical Guidance should serve as a basis for both public and private health services.
Full Text of ICPD+5, Paragraph 63:
(i) In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women’s health, to deal with the health impact of unsafe abortion as a major public-health concern and to reduce the recourse to abortion through expanded and improved family planning services. Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. Post-abortion counselling, education and family planning services should be offered promptly, which will also help to avoid repeat abortions.
(ii) Governments should take appropriate steps to help women avoid abortion, which in no case should be promoted as a method of family planning, and in all cases provide for the humane treatment and counselling of women who have had recourse to abortion.
(iii) In recognizing and implementing the above, and in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women’s health.
1. Key Actions for the Further Implementation of the ICPD Programme of Action, 21st United Nations General Assembly Special Session, June 30 – July 2, 1999 (New York: United Nations, 1999).
The Millennium Development Goals (MDGs) were developed following the adoption of the Millennium Declaration by 189 world leaders assembled at a special UN General Assembly session held in September 2000, called the Millennium Summit.  Based on a number of international conferences held in the 1990s, the MDGs commit member states and the international community to fight poverty and promote human development. These goals are now seen as the primary framework or “road map” for reducing poverty around the world.
The fifth of the eight goals calls for the world’s governments to reduce the maternal mortality ratio by three-quarters between 1990 and 2015.
Of the various direct and indirect causes of maternal deaths, including obstructed labor, sepsis, haemorrhage, and conditions such as malaria that can worsen during pregnancy, unsafe abortion may be technically the easiest to address in some settings. In some countries, unsafe abortion is estimated to cause half of maternal deaths; in these cases, MDG 5 cannot be met unless unsafe abortion is addressed.
The Millennium Development Goals are:
Eradicate extreme poverty and hunger.
Achieve universal primary education.
Promote gender equality and empower women.
Reduce child mortality.
Improve maternal health.
Combat HIV/AIDS, malaria and other diseases.
Ensure environmental sustainability.
Develop a global partnership for development. 
1. United Nations Millennium Declaration, Millennium Assembly of the United Nations, Sept. 6-8, 2000 (New York: United Nations, 2000).
2. Road Map towards the Implementation of the United Nations Millennium Declaration, Report of the Secretary-General (New York: United Nations, 2001).
CARE is committed to protecting and the rights of women, and in our health programs, to reducing families suffering, illness and death. We are also committed to upholding and achieving the MDGs.
Unsafe abortion leads to useless death of women and girls and suffering of their sons and daughters, their mothers and fathers and their husbands, sisters and brothers.
The Maputo Protocol on the rights of African Women directs us to work with partners to advocate for clearer laws, updated guidelines and creation of services for therapeutic abortion in DRC.
Questions, comments, thoughts, concerns welcome!