Unsafe abortion:
A forgotten emergency

For International Women's Day 2019, we explore the hidden
healthcare issue that kills 22,000 women and girls every year

© Gazelle Gaignaire

© Gazelle Gaignaire

Around the world, fewer women are dying during pregnancy or as a result of childbirth.

Significant progress has been made on four of the five main causes of maternal mortality. However, unsafe abortion – the only preventable cause – has been largely forgotten.

Unsafe abortion still accounts for at least one in 12 maternal deaths globally.

When compared to reductions in all the other direct causes of maternal deaths since 1990 – severe bleeding, severe infection, blood pressure disorders and obstructed labour – there has been little improvement.

What is an unsafe abortion?

What is an unsafe abortion?

© Charmaine Chitate/MSF

© Charmaine Chitate/MSF

Defined by the World Health Organisation, an unsafe abortion is when an unwanted pregnancy is terminated either by a person lacking the necessary skills, or in an environment lacking minimal medical standards. Sometimes, both.

  • Abortion, whether safe or unsafe, is a common event worldwide - from 2010 to 2014, approximately one in four pregnancies ended in an induced abortion
  • About 45 percent of all abortions are deemed unsafe
  • More than 22,000 women and girls die each year following an unsafe abortion

When a woman or girl is determined to end her pregnancy she will do so, regardless of the safety and legality of the procedure. Where safe abortion care is not available, she will risk her life with an unsafe abortion, often because the prospect of continuing the pregnancy is unbearable.

The impact of unsafe abortion

The scale of post-abortion complications is enormous: an estimated seven million women and girls are admitted to hospital every year.

Some will be left permanently disabled, some will never be able to carry a child again. However, we will never know the full extent as many women and girls dare not, or cannot, access care.

About 97 percent of unsafe abortions and related deaths occur in Africa, Latin America and southern and western Asia, all regions where Médecins Sans Frontières/Doctors Without Borders (MSF) offers medical assistance to people in need.

A medical emergency

Obstetric surgery at an MSF hospital in Nigeria

© Maro Verli/MSF

© Maro Verli/MSF

In 2017, our staff treated over 22,000 patients for post-abortion complications. In some hospitals where our teams work, up to 30 percent of obstetric complications may be due to unsafe abortion.

A woman or girl may have consulted an unskilled provider, or attempted the abortion herself.

Dangerous methods

The history of unsafe abortion is marked by dangerous methods. Many are not effective, but can still leave lasting damage:

  • Sharp sticks inserted up through the vagina, cervix and into the uterus;
  • ingesting toxic substances such as bleach;
  • inserting herbal preparations into the vagina;
  • inflicting trauma to the abdomen, such as hitting or falling.
"In the operating theatre, examining many of these women, I found trauma marks on the cervix caused by objects such as sticks"
Claire Fotheringham | MSF doctor and women’s health advisor in West Africa

For those that use these unsafe methods, the life-threatening consequences include severe haemorrhage, sepsis, poisoning, uterine perforation or damage to other internal organs.

Urgently admitted to hospital, a woman may need a blood transfusion, major reparative surgery, or a hysterectomy - the complete and irreversible removal of the uterus.

Some women are able to access relatively safer methods, such as medication, on the black market. However, they may still suffer complications due to poor quality, incorrect dosing, inadequate information or a combination of these.

Worst case scenario

In the worst-case scenario, the woman being treated may have been previously refused a safe abortion, only to reappear on death’s door due to an unsafe one.

In the Democratic Republic of Congo, where abortion used to be extremely restricted, emergency department doctor Jean-Paul remains shaken by his direct experience of just such a girl.

Due to the legal restrictions, she had been denied care in the MSF hospital he was working in. She was later brought back, in a coma, and died not long after.

Why women seek an abortion

Why women seek an abortion

© Christina Simons/MSF

© Christina Simons/MSF

A woman may hope to be pregnant one day in the future, but not necessarily right now.

Our experience in countries such as Colombia, Greece, Mozambique and South Africa, to name just a few, confirms the diversity of women and girls facing an unwanted pregnancy:

Married and unmarried, women with children, girls that still go to school, urban women with an education and those from rural villages.

It's common for women who already have children to seek an abortion

Their reasons for wanting an abortion are just as varied.

Some have been using contraception that failed, or ran out due to a limited supply. Some have been coerced into pregnancy, or become pregnant due to sexual violence.

Others have faced financial and emotional hardship, with and without partners or family support. Some have been caught up in a humanitarian crisis and forced to flee for their lives.

Moral judgement and shame

There can be as much shame and stigma attached to the circumstances that created the unwanted pregnancy as the abortion itself.

Like the young woman from Jean-Paul’s neighbourhood, this means many questions need to be faced alone:

Who can I turn to? Where can I go for the help? What are my options? What will it cost? Will it be painful? What will happen to me? What if I can never have children again? What will this mean for me and my family if people find out?

"My head was exploding, I thought, 'My God, what am I going to do?'"
MSF patient | Colombia

Most women have already thought about their options and made the decision before seeking care, while some women may ask for more information before deciding.

An MSF team member discusses family planning with a patient in Bangui, Central African Republic

Our role is to listen and provide the appropriate level of support and information, respecting her decision without judging or influencing her.

Consultation with a trained professional also ensures that a woman understands the risks and benefits of an abortion, knows what she will experience during the process, and has the opportunity to ask questions.

It's common for women who already have children to seek an abortion

It's common for women who already have children to seek an abortion

It's common for women who already have children to seek an abortion

An MSF team member discusses family planning with a patient in Bangui, Central African Republic

An MSF team member discusses family planning with a patient in Bangui, Central African Republic

An MSF team member discusses family planning with a patient in Bangui, Central African Republic

The legal limitations

The legal limitations on abortion

© Morgana Wingard/NAMUH

© Morgana Wingard/NAMUH

The fact that abortion is still criminalised in most countries remains a concern.

The evidence is clear that the number of abortions changes little when there are legal restrictions.

Instead,  where abortion is most restricted, it is more likely to be unsafe. However, where abortion is legal and safe services are available, deaths and disability are greatly reduced.

Prompted by the evidence, some countries have rethought their laws.

Legislation in Democratic Republic of Congo changed in April 2018. Since then, all medical facilities have the obligation to provide termination of pregnancy for women who have been victims of rape or sexual abuse, or whose physical or mental health is at risk.

Mozambique revised its stance four years earlier, in 2014, allowing for cost-free abortion for all women in the first trimester, and up to 24 weeks under special circumstances.

Although a significant proportion of the population may remain opposed, as in Mozambique, when laws do ease they can lead to palpable change for women — like for Amanda featured in this video, who could now have access to an option that is truly safe.

Barriers in the healthcare system

Barriers in the healthcare system

© Marta Soszynska/MSF

© Marta Soszynska/MSF

Liberalisation and decriminalisation of abortion are important steps, but they do not guarantee the availability of safe abortion care.

Many health systems respond slowly, and inconsistently, to change.

In Mozambique, clinical standards for safe abortion were only defined in 2017. Institutional opposition, resistance from health workers and decision-maker with limited knowledge have all hindered its implementation. This means there are still many women who don’t know how to access services.

In Colombia, significant decriminalisation was achieved 12 years ago. However, in the port cities of Buenaventura and Tumaco, MSF found general ignorance about the current scope of safe abortion care. 

Healthcare workers who should have been prepared to undertake this care were not even aware it was part of their duty.

“They say, ‘Come back in a few weeks.’ ‘Let's go to the psychology ward to see if you are really sure.’"
Alejandrina Camargo | MSF doctor in Colombia, on the obstacles devised by some healthcare providers

For a woman or girl with an unwanted pregnancy, it can be hard to overcome this sometimes strong resistance, which may even extend to being denied care at all.

The barriers can be bureaucratic.

In Athens, where MSF supports migrants, asylum-seekers and refugees to access safe terminations in the public health system, women join a waiting list more than four weeks long just to have their first appointment.

More appointments with more health professionals, especially doctors, follow. Some patients face additional obstacles, because they didn’t have their social security identification with them, or attended an appointment without a translator.

In Greece, the legal limit is 12 weeks’ gestation, so women face a race against the clock to be able to end their pregnancy because of the many hurdles in their way.

Simplifying access to safe abortion

Simplifying access to safe abortion

© Sanna Gustafsson/MSF

© Sanna Gustafsson/MSF

Termination of pregnancy is a safe and effective medical act.

It is usually managed with tablets (medication abortion) or with a minor procedure under local anaesthesia (manual vacuum aspiration, or MVA). Both of these abortion methods are less risky than an injection of penicillin.

Medication abortion involves two drugs, mifepristone and misoprostol, and a total of only five pills. It is the preferred method for many women, as it is less invasive and can be completed in the privacy of their own home. 

Doctors are not necessary to provide these services; trained midwives and nurses can provide both abortions in hospitals and health centres.

Support for healthcare staff

Even so, in places where health services are stretched, medical providers can benefit greatly from additional support — further training, institutional back-up, mentoring and guidance.

In Rustenburg, South Africa, this is an important component of nurse Kgaladi Mphahlele’s work as Choice of Termination of Pregnancy Manager on behalf of MSF.

The district health service is committed to providing safe abortion care, but staff can be unsure of the correct methods and protocol.

Some staff also need moral support in the face of judgement and stigma from colleagues in the workplace.

Even knowing the importance of this care, other healthcare providers still have to confront their own attitudes in providing the service, so peer support is important.

Making abortion safe

Making abortion safe

© Charmaine Chitate/MSF

© Charmaine Chitate/MSF

Safe abortion care is a package of essential health services: management of post-abortion complications, safe termination of pregnancy, and provision of contraceptives.

These services need to be timely, reliable, confidential, skilled and compassionate. They must be provided by people who have been properly trained.

Access to contraception

Modern contraception is an essential component in reducing unsafe abortions.

However, increasing access to contraception alone is not a sufficient enough solution. Instead, contraception goes hand in hand with safe abortion care as a strategy to reduce unwanted pregnancies, unsafe abortions and maternal deaths.

"The woman has the freedom to decide whether she wants to be a mother at the moment."
Ana Paula de Sousa | MSF midwife in Mozambique

MSF is working with its staff, local communities, departments or ministries of health and other non-governmental healthcare providers to improve access to contraceptives, post-abortion care and to safe termination of pregnancy for women and girls lacking access to healthcare or caught in a humanitarian crisis.

Respect, not judgement

Unwanted pregnancy and unsafe abortion have a serious medical impact on women and girls in the many “low-resource” and conflict-affected countries in which MSF works.

The consequences are also felt by their families and friends, caregivers - including MSF staff - and their wider community. And, as a medical and humanitarian organisation, MSF remains committed to providing safe abortion care to reduce this avoidable, and often overlooked, suffering.

Instead of judgement, what a woman needs is healthcare that will respect the reason why she has come forward; that ensures she can talk with a trained professional; and provides her with high-quality abortion care.