Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries

Summary

Background

Complications from unsafe abortion are believed to account for the largest proportion of hospital admissions for gynaecological services in developing countries. The WHO estimates that one in eight pregnancy-related deaths result from unsafe abortions. The social stigma and legal restrictions associated with abortion in many countries means that data on the magnitude of this problem are scarce; this article estimates the rate and numbers of hospital admissions resulting from unsafe abortions in developing countries to help quantify the problem.

Methods

National estimates of abortion-related hospital admissions in women aged 15–44 years were compiled for 13 developing countries: Africa (Egypt, Nigeria, and Uganda), Asia (Bangladesh, Pakistan, and the Philippines), and Latin America and the Caribbean (Brazil, Chile, Colombia, Dominican Republic, Guatemala, Mexico, and Peru). These data were combined with supplementary data from five countries in sub-Saharan Africa (Burkina Faso, Ghana, Kenya, Nigeria, and South Africa) to give estimates for the three world regions.

Findings

The annual hospitalisation rate varies from a low of about 3 per 1000 women in Bangladesh to a high of about 15 per 1000 in Egypt and Uganda. Nigeria, Pakistan, and the Philippines have rates of 4–7 per 1000, and two countries in Latin America with recent data have rates of almost 9 per 1000. In the developing world as a whole, an estimated five million women are admitted to hospital for treatment of complications from induced abortions each year. This equates to an average rate of 5·7 per 1000 women per year in all developing regions, excluding China. By comparison, in developed countries complications from abortion procedures or hospitalisation are rare.

Interpretation

These results help quantify the magnitude of the adverse health effects of unsafe abortion in developing countries and highlight the need for improved access to post-abortion care. The provision of abortion services is changing to include the drug misoprostol and this could reduce the severity of abortion complications and the number of women who are hospitalised. Researchers will need to monitor these changes to provide countries with up-to-date information on illness and death from unsafe abortion. Improved contraceptive services are necessary to prevent unintended pregnancy. However, increasing access to safe abortion services is the most effective way of preventing the burden of unsafe abortion, and remains a high priority for developing countries.

Introduction

Unsafe abortion has substantial detrimental consequences for society, negatively affecting women and their families, public-health systems, and ultimately, economic productivity. The WHO defines unsafe abortion as a procedure to terminate an unintended pregnancy undertaken either by individuals lacking the necessary skills or in an environment that does not meet basic medical standards, or both.¹ For four out of ten women, almost all in developing countries, abortion is legally restricted (ie, not permitted under any circumstances, or legally permitted to save the life of a woman, to protect physical health, or when pregnancy results from rape or incest). For other women, abortion is legally permitted within broad criteria but for some of these women access to safe abortion services is poor. In both circumstances, women resort to unsafe and clandestine abortion services.²

Where abortion is highly restricted by law or socially stigmatised, research on this issue is difficult, reliable data are scarce, and estimates become an essential tool.³ The WHO has provided global and regional estimates of abortion-related mortality and incidence of abortion over the past 15 years. The organisation estimates that 68 000 unsafe abortion-related deaths occur annually; that about one in eight of all pregnancy-related deaths result from unsafe induced abortion; that about 19 million unsafe abortions take place each year worldwide;⁴ and that abortions happen to women of all ages, throughout their reproductive years.⁵ Estimates have also been made of the disability burden of unsafe abortion (disability-adjusted life years [DALYs]), integrating the loss of productive life resulting from both death and illness.⁶ These estimates show that unsafe abortion is responsible for the loss of about 5 million years of productive life, or 14% of all DALYs lost from pregnancy-related conditions.⁷ However, in view of the limitations of the available evidence base and estimation methodologies, this burden has probably been greatly underestimated.⁸ For example, the effect on women who have complications but who do not seek or receive medical care is likely to be underestimated; the long-term impact of unsafe abortion on women's health, through increased risks of infertility, fistula, and other sequelae, is also difficult to quantify.

This article focuses on one aspect of the health consequences of unsafe abortion that has not been addressed comprehensively elsewhere: the number of women admitted to hospital for treatment of complications resulting from unsafe abortion. It compiles comparable national data for hospitalisation from unsafe abortion for 13 countries. Further, an estimate of the number of women hospitalised for abortion complications in the developing world as a whole was calculated on the basis of country estimates. This rough estimate is justified because of the importance of having even an approximate measure of the impact of unsafe abortion at regional and global levels on women's health, and on health-care infrastructures. Reliable national studies on all aspects of unsafe abortion, including hospitalisation for complications, are scarce, and are likely to remain so in the short term because the factors that account for the scarcity of data—including the illegality of the procedure and the fact that abortion is stigmatised irrespective of its legal status—are long-standing and will be slow to change.