PRB

(September 2009) Unmet need for family planning, unintended pregnancy, and unsafely performed abortion are linked. Unintended pregnancy is a common outcome for the more than 200 million women worldwide who want to stop having children or delay their next pregnancy but are not using an effective method of contraception. It is also a primary factor in the 46 million abortions that occur each year globally; more than one-half of unintended pregnancies result in abortion, and nearly half of all abortions are performed in an unsafe or unhygienic way.¹

Unsafely performed abortion puts the lives of women at risk, leading to the death of 68,000 girls and women every year. Millions more suffer long-term injuries from often life-threatening complications. In many poor countries, treatment of these complications consumes up to half of hospital budgets for obstetrics and gynecology. Estimates derived from data from the World Health Organization (WHO) predict that at prevailing rates, one in five women in developing countries will be hospitalized for complications of unsafely performed abortion at some time in their lives.²

Each year, women in less developed countries have 75 million unintended pregnancies (an estimated one-third of all their pregnancies). Many of these women still lack access to modern contraception (defined as female and male sterilization, oral hormonal pills, the intrauterine device (IUD), the male condom, injectables, the implant, vaginal barrier methods, the female condom, and emergency contraception) or, for various reasons, are not using contraception. Women who did not intend to become pregnant often resort to an abortion, typically carried out beyond the reach of health services or providers. With 97 percent of unsafely performed abortions and 99 percent of maternal deaths occurring in less developed countries, it is clear that improving the knowledge of and access to contraception are essential to prevent the unintended pregnancies that lead women to risk an unsafely performed abortion.³

Unsafely Performed Abortion Is Widespread, Especially Where Abortion Is Illegal

Nearly one in 10 pregnancies worldwide ends in unsafely performed abortion, defined by the WHO as a “procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both.” WHO estimates that one in eight pregnancy-related deaths globally are a result of an unsafely performed abortion. The toll at country levels is more devastating: Unsafely performed abortions are responsible for as many as 50 percent of maternal deaths in sub-Saharan Africa.

Estimates of Annual Incidence of Unsafely Performed Abortion, 2000

Source: WHO, Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe

Abortion and Associated Mortality in 2000, 4th ed. (2004).

In countries where abortion is illegal, women who can afford to can often find a private physician, nurse, or midwife willing to perform a safe abortion; women who cannot afford or access services may resort to unsafe practices or unskilled practitioners. However, even legalization does not guarantee sufficient care. In countries such as India where abortion has been legal for decades, other factors—poverty, inaccessibility, and social pressures—prevent women from getting skilled care.

Increased access to and use of contraception would lower the incidence of abortion, thereby putting the lives of women at less risk of lifelong injury or death. But there are barriers that prevent women who want to prevent a pregnancy from using a contraceptive method.

Barriers to Contraceptive Use

Women in developing countries who want to avoid a pregnancy do not use contraceptives mainly because of insufficient knowledge about the methods; fear of social disapproval or perception of husband opposition; fear of side effects and concerns about health; and problems with access and cost.

A woman’s educational level, literacy, and access to media and health services all influence whether she uses contraceptives. Women with lower levels of education and literacy and poorer women are less likely to use contraception. However, lack of knowledge about contraception is no longer the single major reason for not using contraception. Over the past couple of decades women have become more familiar with different types of contraception. A more common reason is fear of health or other side effects.

In some societies where having a large number of children remains highly valued, use of contraception also carries social stigma and can be a point of contention between sexual partners. Social stigma can be overcome through mobilizing the support of political and religious leaders, and building a broad constituency for smaller, healthier families at the community level. Bangladesh achieved a high rate of contraceptive use through building such support, while Pakistan, although culturally similar, did not solidly support family planning until decades after Bangladesh did. Even as fertility has fallen, unsafely performed abortion remains a means of fertility control in Pakistan, which has more than twice the rate of women hospitalized for complications of abortion as Bangladesh. The rate of unsafely performed abortion in Pakistan is furthermore likely to be substantially underestimated because of the social stigma surrounding abortion.⁴

Access and cost remain challenges as well. The poorest women are the least likely to be able to pay for family planning services. Public funds for family planning are most wisely spent toward reaching the poorest populations, who frequently have limited access to service providers. Although family planning programs have been successful in educating women about contraception, more work needs to be done to address perceived health risks and social pressures and expand access. Information and counseling for women and men can overcome many of these barriers.

Men can play a large role in addressing social pressure and stigma that impede widespread family planning. Misperceptions by women of their husband’s views on contraception and lack of spousal communication about family planning are obstacles that can be overcome. While some husbands oppose contraception, others support family planning or may be encouraged to support it through programs that involve men in couples counseling, and programs that promote the health benefits of child spacing for mothers and infants. According to a recent WHO review of reproductive health programs involving men, the evidence is significant that even a single individual or couple counseling session with men can lead to increased support for contraceptive use.⁵

Increased Contraceptive Use, Decreased Abortion

Two-thirds of unintended pregnancies in developing countries occur among women who are not using any method of contraception. On first glance, it seems self-evident that increased contraceptive use would lower the incidence of unintended pregnancy, thereby lowering abortion rates. However, the relationship between contraceptive use and abortion rates is hampered by the scarcity and poor quality of the data on abortion. The topic of abortion is fraught with social, political, and ethical complexities, and abortions that take place outside the public health care system are often unreported. Contraceptive use, especially among unmarried, sexually active women, is also difficult to measure. Most surveys include only women who are married or in union. However, a number of surveys have found that adolescents are less well-informed and have less access to contraceptives than do married or adult women. Adolescent girls feel unwelcomed at family planning centers that are not youth friendly and where they fear their visit will not be confidential. These factors contribute to the high rate of unintended pregnancies and unsafely performed abortions among 15-to-19-year-olds in Africa, who account for 25 percent of unsafe abortions, a much higher percentage than in other less developed regions.⁶

The experience of the former Soviet republics of Kazakhstan, Uzbekistan, and the Kyrgyz Republic in the mid-1990s illustrates the correlation between increased contraceptive use and decrease in abortion. What makes studies from Central Asia unique and important is the availability of data on abortion rates since the practice was widely available and carried less social stigma than in other parts of the world. Widespread availability of free abortion services coupled with the unavailability of contraceptives led to very high rates of abortion during the Soviet era. In 1990, the annual abortion rate was 181 per 1,000 women of reproductive age and it was estimated that a woman had on average five abortions over the course of her life. After the Soviet era, reproductive health services programs were expanded to promote and provide contraception. Data from demographic and health surveys and the ministries of health from all three countries showed marked declines in the incidence of abortion as contraceptive use rose in the mid-1990s.

Another example is Bangladesh. Researchers studied pregnancies from 1979 to 1998 in two similar rural areas and found that improved access to family planning led to fewer abortions.⁷

However, the relationship between contraceptive use and abortion is not always so clear. A 2003 study from the Guttmacher Institute found that rising contraceptive use correlates with reduced abortion incidence when fertility is constant. In cases where fertility rates are falling, abortion rates and contraceptive use frequently rise simultaneously because contraception supply cannot keep up with demand or because public education campaigns have not reached the general population. For example, in South Korea, contraceptive use and the rate of abortion rose simultaneously until abortion rates peaked in the late 1970s. After that time, abortion rates fell while contraceptive use continued to rise. During this period, South Korea was undergoing a transition from high to low fertility; part of the demand for smaller families was being met through abortion.⁸

Meeting Increased Demand for Contraception

The deaths of tens of thousands of women each year from unsafely performed abortion are preventable. As developing countries make the transition to smaller families, the need for effective contraception will only increase. To avoid a rise in unsafely performed abortion, public expenditures and private investment that support universal access to contraception must keep pace with increased demand in order to ensure women’s reproductive rights and health. Increasing modern contraceptive use by addressing women’s and men’s concerns and by increasing availability through expanding method choice, access, and affordability will prevent unsafely performed abortion.

Eric Zuehlke is an editor at the Population Reference Bureau.