Human Reproduction, Vol.32, No.6 pp. 1160–1169, 2017 Advanced Access publication on April 10, 2017 doi:10.1093/humrep/dex071
OPINION
Induced abortion ESHRE Capri Workshop Group *,† *Correspondence address. P.G. Crosignani, IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, Via M. Fanti, 6, 20122 Milano, Italy, E-mail: [email protected]
Submitted on November 25, 2016; resubmitted on March 15, 2017; accepted on March 24, 2017
ABSTRACT: Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in
the period 2010–2014 was 35 abortions per 1000 women (aged 15–44 years), five points less than the rate of 40 for the period 1990–1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy. Key words: unintended pregnancy / abortion prevalence / availability / abortion methods / safety / post-abortion care / prevention
Introduction Abortion is common; around one in four women will have an abortion at some time in their lives. In developing countries, abortion is often unsafe and a significant cause of maternal morbidity and mortality. Between 2003 and 2009, induced abortion was estimated to have been responsible for 193 000 or 7.9% [95% uncertainty interval (UI): 4.7–13.2%] of the global total of 2 44 3000 maternal deaths (Say et al., 2014). Although a simple and safe procedure, abortion remains controversial. Its availability depends not on medical or public health need but on religious, moral and political beliefs. Abortion is legal on broad grounds in most European countries. Women seeking abortion are not different from those seen daily by reproductive medicine specialists in their clinics, operating theatres and delivery suites. Healthcare providers working in reproductive medicine should be informed about abortion and abortion care, even if they do not provide it. This article summarizes key points on abortion, its prevalence, availability, methods and safety, on post-abortion care and on efforts at preventing unintended pregnancy. Searches on abortion topics were performed in Medline, Popline, EMBASE, the Cochrane library and the Social Sciences Citation Index
databases for relevant English language publications from 1970 to 2016. Summaries were discussed at the ESHRE Capri Workshop.
Incidence Estimating the incidence of induced abortion is difficult. In countries with liberal abortion laws and reporting requirements, under-reporting is common and the introduction of medical abortion may have further compounded this problem. In countries with restrictive laws where most induced abortions are performed clandestinely, no centralised registries are available and estimates must be derived indirectly from published studies, hospital records, surveys of women, expert opinion, etc. The most recent abortion estimates for all women aged 15–44 years, calculated using a Bayesian time series model, indicate that in the period 2010–2014 the global abortion rate was 35 (90% UI: 33–44) abortions per 1000 women—five points less than the rate of 40 (90% UI: 39–48) for the period 1990–1994 (90% UI for decline: −11 to 0) (Table I) (Sedgh et al., 2016). Almost all the decline occurred in developed regions: from 46 in 1990–1994 to 27 in 2012–2014. In the developing world, the small decline from 39 (37–47) to 37 (34–46) was not
†
The list of the ESHRE Capri Workshop Group contributors is given in the Appendix.
© The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please e-mail: [email protected]
1161
Abortion: rates, laws, techniques, safety and prevention
statistically significant. Within the developing regions, the highest rates were found in the Caribbean (~60–65). Rates showed little or no change over the period 1990–2014 in Africa, and they increased in Latin America and decreased in most of Asia. Rates decreased throughout Europe as a whole, from 52 (48–64) in 1990–1994 to 30 (27–38) in 2010–2014; in Western Europe, however, the rate increased by five points (1–11) between 1990–1994 and 2010–2014 (Table I). Currently, an estimated 25% of all pregnancies conceived end in induced abortion. In contrast to earlier reports (Sedgh et al., 2012), the most recent abortion estimates no longer distinguish between ‘safe’ and ‘unsafe’ abortions since several recent developments, such as increased use of both manual vacuum aspiration (VA) instead of sharp curettage and of medical abortion, including use of misoprostol by women themselves, have blurred the distinction (Ganatra et al., 2014).
type of provider, medical procedure, counselling, parental consent and funding, which in practice restrict access to abortion. While broadly legal across the European Union with the exception of Poland, Ireland and Malta, the legal conditions surrounding access and procedures vary substantially from country to country, revealing the lack of evidence informing legislative decisions. In the USA, individual states have accelerated the adoption of abortion restrictions (57 restrictions were passed in the year 2015 alone). While claiming to increase women’s safety, none of these laws are based on evidence. Conversely, false information, increased waiting periods and lack of reimbursement are all designed to increase women’s burden, with the potential to increase maternal complications by delaying abortion care (Guttmacher Institute, 2015).
Abortion laws
Medical abortion using mifepristone with misoprostol and surgical abortion provided by trained healthcare providers, are both highly effective (Ireland et al., 2015). In most countries where abortion is legal most procedures are carried out in the first trimester.
Abortion laws are typically described as a continuum from ‘highly restrictive’ to ‘mostly legal’ based on the combination of different indications: to save the woman’s life, preserve her physical health, preserve her mental health, for rape or incest, foetal impairment, economic or social reasons or no restrictions. In 2013, 99% of women lived in countries where abortion was permitted to save their lives while less than one-third of countries (30%) allowed abortion without restriction (Fig. 1) (United Nations, 2014). Since the mid-1990s there has been progress towards liberalized access to abortion. Altogether 56 countries liberalized their laws while eight countries voted on more stringent restrictions. Profound disparities exist between developed and developing countries (Fig. 1). Only a minority of developing countries permit access to abortion on request (16%) or for socio-economic reasons (20%), while a vast majority of developed countries grant access for both indications (71 and 82%, respectively). The least developed countries maintain the most restrictive laws; only 6% allow abortion for socio-economic reasons and 4% on request (United Nations, 2014). The legal status of abortion has no connection with overall incidence rates. In 2010–2014, overall abortion rates were estimated at 37 (35–51) per 1000 women in countries with no legal grounds for abortion but were lower at 34 (29–46) per 1000 in countries where abortion is legal on request (Sedgh et al., 2016). Restricting access to abortion does not necessarily deter women from seeking it but does largely determine abortion-related mortality and morbidity as many women resort to unsafe, clandestine procedures. In 2011, rates of unsafe abortion were four times higher in countries with restrictive policies as compared to countries with liberal policies (26.7/1000 women versus 6.1/1000 women) (United Nations, 2014). The direct impact of the legal status on abortion-related mortality was clearly visible in Romania where maternal mortality dropped by 50% in
OPINION
Induced abortion ESHRE Capri Workshop Group *,† *Correspondence address. P.G. Crosignani, IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, Via M. Fanti, 6, 20122 Milano, Italy, E-mail: [email protected]
Submitted on November 25, 2016; resubmitted on March 15, 2017; accepted on March 24, 2017
ABSTRACT: Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in
the period 2010–2014 was 35 abortions per 1000 women (aged 15–44 years), five points less than the rate of 40 for the period 1990–1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy. Key words: unintended pregnancy / abortion prevalence / availability / abortion methods / safety / post-abortion care / prevention
Introduction Abortion is common; around one in four women will have an abortion at some time in their lives. In developing countries, abortion is often unsafe and a significant cause of maternal morbidity and mortality. Between 2003 and 2009, induced abortion was estimated to have been responsible for 193 000 or 7.9% [95% uncertainty interval (UI): 4.7–13.2%] of the global total of 2 44 3000 maternal deaths (Say et al., 2014). Although a simple and safe procedure, abortion remains controversial. Its availability depends not on medical or public health need but on religious, moral and political beliefs. Abortion is legal on broad grounds in most European countries. Women seeking abortion are not different from those seen daily by reproductive medicine specialists in their clinics, operating theatres and delivery suites. Healthcare providers working in reproductive medicine should be informed about abortion and abortion care, even if they do not provide it. This article summarizes key points on abortion, its prevalence, availability, methods and safety, on post-abortion care and on efforts at preventing unintended pregnancy. Searches on abortion topics were performed in Medline, Popline, EMBASE, the Cochrane library and the Social Sciences Citation Index
databases for relevant English language publications from 1970 to 2016. Summaries were discussed at the ESHRE Capri Workshop.
Incidence Estimating the incidence of induced abortion is difficult. In countries with liberal abortion laws and reporting requirements, under-reporting is common and the introduction of medical abortion may have further compounded this problem. In countries with restrictive laws where most induced abortions are performed clandestinely, no centralised registries are available and estimates must be derived indirectly from published studies, hospital records, surveys of women, expert opinion, etc. The most recent abortion estimates for all women aged 15–44 years, calculated using a Bayesian time series model, indicate that in the period 2010–2014 the global abortion rate was 35 (90% UI: 33–44) abortions per 1000 women—five points less than the rate of 40 (90% UI: 39–48) for the period 1990–1994 (90% UI for decline: −11 to 0) (Table I) (Sedgh et al., 2016). Almost all the decline occurred in developed regions: from 46 in 1990–1994 to 27 in 2012–2014. In the developing world, the small decline from 39 (37–47) to 37 (34–46) was not
†
The list of the ESHRE Capri Workshop Group contributors is given in the Appendix.
© The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please e-mail: [email protected]
1161
Abortion: rates, laws, techniques, safety and prevention
statistically significant. Within the developing regions, the highest rates were found in the Caribbean (~60–65). Rates showed little or no change over the period 1990–2014 in Africa, and they increased in Latin America and decreased in most of Asia. Rates decreased throughout Europe as a whole, from 52 (48–64) in 1990–1994 to 30 (27–38) in 2010–2014; in Western Europe, however, the rate increased by five points (1–11) between 1990–1994 and 2010–2014 (Table I). Currently, an estimated 25% of all pregnancies conceived end in induced abortion. In contrast to earlier reports (Sedgh et al., 2012), the most recent abortion estimates no longer distinguish between ‘safe’ and ‘unsafe’ abortions since several recent developments, such as increased use of both manual vacuum aspiration (VA) instead of sharp curettage and of medical abortion, including use of misoprostol by women themselves, have blurred the distinction (Ganatra et al., 2014).
type of provider, medical procedure, counselling, parental consent and funding, which in practice restrict access to abortion. While broadly legal across the European Union with the exception of Poland, Ireland and Malta, the legal conditions surrounding access and procedures vary substantially from country to country, revealing the lack of evidence informing legislative decisions. In the USA, individual states have accelerated the adoption of abortion restrictions (57 restrictions were passed in the year 2015 alone). While claiming to increase women’s safety, none of these laws are based on evidence. Conversely, false information, increased waiting periods and lack of reimbursement are all designed to increase women’s burden, with the potential to increase maternal complications by delaying abortion care (Guttmacher Institute, 2015).
Abortion laws
Medical abortion using mifepristone with misoprostol and surgical abortion provided by trained healthcare providers, are both highly effective (Ireland et al., 2015). In most countries where abortion is legal most procedures are carried out in the first trimester.
Abortion laws are typically described as a continuum from ‘highly restrictive’ to ‘mostly legal’ based on the combination of different indications: to save the woman’s life, preserve her physical health, preserve her mental health, for rape or incest, foetal impairment, economic or social reasons or no restrictions. In 2013, 99% of women lived in countries where abortion was permitted to save their lives while less than one-third of countries (30%) allowed abortion without restriction (Fig. 1) (United Nations, 2014). Since the mid-1990s there has been progress towards liberalized access to abortion. Altogether 56 countries liberalized their laws while eight countries voted on more stringent restrictions. Profound disparities exist between developed and developing countries (Fig. 1). Only a minority of developing countries permit access to abortion on request (16%) or for socio-economic reasons (20%), while a vast majority of developed countries grant access for both indications (71 and 82%, respectively). The least developed countries maintain the most restrictive laws; only 6% allow abortion for socio-economic reasons and 4% on request (United Nations, 2014). The legal status of abortion has no connection with overall incidence rates. In 2010–2014, overall abortion rates were estimated at 37 (35–51) per 1000 women in countries with no legal grounds for abortion but were lower at 34 (29–46) per 1000 in countries where abortion is legal on request (Sedgh et al., 2016). Restricting access to abortion does not necessarily deter women from seeking it but does largely determine abortion-related mortality and morbidity as many women resort to unsafe, clandestine procedures. In 2011, rates of unsafe abortion were four times higher in countries with restrictive policies as compared to countries with liberal policies (26.7/1000 women versus 6.1/1000 women) (United Nations, 2014). The direct impact of the legal status on abortion-related mortality was clearly visible in Romania where maternal mortality dropped by 50% in
