Reproductive health is intricately interwoven into issues surrounding women’s and children’s health, the spread of sexually transmitted diseases, poverty, education, gender equality and most importantly human rights. Therefore, improving access to reproductive health is central to the process of social and economic development. The WHO has defined an unsafe abortion as the termination of an unintended pregnancy either by an individual lacking the necessary skills or in an environment that does not conform to the minimal medical standards or both. Out of the 43.8 million abortions that were performed in 2008, approximately 22 million were carried out under unsafe conditions. Most unsafe abortions occurred in Sub-Saharan Africa (97%), Latin America (95%) and Asia (55%). Almost all abortions that occurred in developed countries were unsafe. Unsafe abortions continue to contribute to the unacceptable high rates of maternal deaths worldwide.
Maternal death is classified as the death of a woman during pregnancy or within 42 days after the termination of a pregnancy. According to the WHO (2011) unsafe abortions were related to 68,000 maternal deaths every year—that is eight deaths every hour—and left 5 million women with debilitating disabilities. Besides maternal deaths, unsafe abortions have more far reaching consequences to the family and have left more than 220,000 children motherless. Unsafe abortions account for approximately 3.9% of the total causes of maternal deaths. Provision of safe abortion services is by far one of the most contentious, emotional and political issues of this century. It is a question of defending a woman’s right to choose what to do with her body as much as it is about protecting the unborn fetus. In most cases, women decide to carry out an abortion because the pregnancy is unwanted. The leading causes of death that result from induced abortions are sepsis, hemorrhage and poisoning from substances such as bleach, turpentine and chloroquine that are used to induce an abortion.
There are currently four levels of interventions that exist to alleviate the incidences of unsafe abortions and they can be categorized into pre and post pregnancy. Pre-pregnancy interventions are aimed at reducing unwanted pregnancies while post pregnancy interventions are aimed at ensuring the safety of an abortion. At the pre-pregnancy stage we have primary interventions that involve improving access to modern family planning methods including emergency contraception and comprehensive sexual education. Of the approximately 208 million pregnancies that occur annually across the globe, roughly 44% are unintended—either unplanned/mistimed or unwanted. Worldwide, girls aged 15-19 account for 19% of all pregnancies, a vast majority of which are unintended (Loaiza,Liang). At least half of these pregnancies result in abortion often times under unsanitary and unsafe conditions. Hence the need for sexual education among adolescents.
Sexual education is vital because it not only teaches adolescents to make informed decisions about their reproductive health, but it is essential to teaching them about sexually transmitted diseases, contraception and teenage pregnancies. For sexual education to be considered comprehensive it should cover a myriad if topics ranging from sexual and reproductive physiology, contraception, unintended pregnancy, HIV/STI prevention, gender, sexual and reproductive rights, values and interpersonal skills.(keogh et al). A comprehensive sexual education program needs to be grounded in norms and cultural values where the youth are supported and feel comfortable accessing those services. From the local and community level to the policy level (this can take the form of subsidized prices for contraception and contraception counselling services).
Attempts to introduce sexual education programs at the primary and secondary levels in developing countries has been met with criticism by some leaders who claim sex education corrupts young children by introducing immorality. Many youths lack the necessary knowledge to make decisions about sexual education. We live in a society that is in denial that teenagers are having sex, we should instead focus on equipping them with the skills necessary to make the right decisions. Youths are engaging in sex at a much younger age and thus we have a social responsibility to educate them about safe intercourse. Today, children have internet access which is host to all kinds of content and are thus prone to be misinformed.
Studies propose that contraceptive use has been associated with the reduction of close to 230 million pregnancies per year and as such besides abstinence, (Ahmed S) family planning—particularly Long Acting Reversible Contraceptive Methods (LARCs)—is the most effective method of preventing unwanted pregnancies and lowering the incidence and burden associated with death and disability related to complications of pregnancy and childbirth. Approximately 91% of governments in LMICs report integrating some form of support for family planning into their health system. National support for contraceptive programmes proved successful in reducing abortion rates in Turkey, Switzerland, Tunisia, Bulgaria, Kazakhstan, Kyrgyzstan and Uzbekistan. Family planning methods range from permanent to semi-permanent (lasting anywhere between 3-7 years), short term, traditional and fertility based. The different types of contraceptives include:
1) sterilization: tubal ligation and vasectomies
2) LARCs : IUDs and implants,
3) short term methods: injectables, oral contraceptive pills, patches, rings, emergency contraceptives
4) fertility based and barriers: condoms and Lactational Amenorrhea
5) traditional: withdrawal and herbs. Female sterilization and Injectables are the most common methods of contraception in Asia and Africa respectively.
While LARCs are the most effective as they depend less on the user, condoms and pills may need to be taken before every sex act. Individuals in LMICs mainly access contraceptives through: health facilities, commercial outlets and community-based approaches. The latter method is more effective in remote areas where access may be somewhat limited.
According to the United States Agency for International Development(USAID), 225 million women in developing countries have an unmet need for contraception, (singh,Schiavone))and if this need could be met, there will be a dramatic improvement on not only health related outcomes such as a reduction of maternal and infant mortality but also other downstream effects of higher educational attainment, healthier families, increasing women’s earning potential, empowering women to fully engage in socioeconomic development and improving the sustainability of the environment. Access to contraception in developing countries is threatened by a limited choice of contraceptives and a lack of LARCs. In places with poor contraceptives access, women are forced to rely on traditional/fertility-based methods such as withdrawal and herbs that have reduced efficiency. Despite the fact that emergency contraceptives are included in the WHO essential medicine guidelines they are less accessible in developing countries as they are not incorporated into national programs. Even though contraceptives may be readily available a woman may need permission to use it from a partner, mother-in-law or another family member. Additionally, some women’s concern of the side effects may preclude them from using contraceptives. Further challenges involve a lack of trained personnel to educate women and men on how to properly use contraceptives.
The second phase of the intervention occurs after the woman has an unplanned pregnancy and makes the difficult decision to terminate it. At this level the only intervention is to ensure that women have access to abortion services. No modern method of contraception is 100% fail safe and in cases when a woman is forced to have sexual intercourse sexual education and family planning become moot. While inducing an abortion is a personal decision, it is a shared responsibility. In case of an unwanted pregnancy, a woman needs to have access to safe legal abortion services. Modern medicine has evolved from 5000 years ago when the Chinese used mercury to induce abortion. The choice of a method of abortion is influenced by the length of gestation. WHO guidelines recommend medical/non-surgical abortion for pregnancies that are below 9 weeks, in particular a combination of mifepristone(200mg) and misoprostol(80 micrograms) that act to prevent progesterone function and stimulate contractions respectively. While misoprostol is readily available and cheap in most countries, mifepristone is very expensive and hard to obtain in most instances.
In the absence of mifepristone, a low dose of misoprostol can be used. It has also been proven to be effective in the management of uncomplicated incomplete abortion (Zhang, Faundes etal). Vacuum aspirations either manual or electrical can be used for pregnancies that are more than 12 weeks but less than 14 weeks. Vacuum aspiration has replaced sharp curettage because it is faster, safer, more comfortable, associated with less blood loss and is better suited for low-resource settings as it requires less and local anesthesia—making it more practical for use in developing countries as it can be administered by a skilled health worker such as a midwife.(Sibuye) Unlike vacuum aspiration, curettage is more expensive, uses general anesthesia and may be associated with severe complications. Surgical methods are recommended for pregnancies greater than the 12-14 week range. Some of the methods used include dilation and curettage (D&C) and dilation and evacuation (D&E).
Despite the fact that making abortion safe for women has been recognized as a critical component of achieving MDGs and later the SDGs, a number of countries still have restrictive abortion laws. In addition to restrictive laws, community stigma may preclude women from seeking care until they are very ill. And then it might be too late. A prospective study in Libreville, Gabon revealed that women who present with abortion complications may be forced to wait as much as 23.8 hours before they can receive care.(Mayi Tsonga) In countries with strict abortion laws, the poor and marginalized communities may often bear the brunt of the burden. Affluent women who live in the city may sometimes get access to safe abortion services through private providers. Women who may be unable to access safe abortion services often result to rudimental options to induce abortions. These methods can be characterized through the route of administration:
1) through the mouth(turpentine and bleach
2) placed in vagina or cervix (potassium permanganate tablets and misoprostol)
3) intramuscular injections(two doses of cholera immunizations)
4) foreign bodies placed in the uterus through the cervix(ballpoint pen and chicken bone)
5) enemas(soap)
6) physical trauma(lifting heavy weights or jumping from the top of a roof or staircase).
Because misoprostol is available over the counter in some LMICs, it can also sometimes be used to induce abortion at the home setting. For instance in Brazil, 70% of women who are hospitalized due to abortion complications reported having used the drug (Costa). In some countries, while abortion may be legal, safe abortion services may not be readily accessible ( Grimes at al). In many developing countries, pharmacies/chemists may be the only health care services that are easily accessible. In cases when the pharmacists do not know how to provide the necessary services, they should be aware of the appropriate referral protocol.
Regardless of whether or not a woman lives in country that either permits or does not permit abortion, her average chance of having an induced abortion is much the same. Data has consistently shown that restrictive laws do not stop women from having abortions. Women who live In countries where abortion is prohibited in all cases other than to save a woman’s life have a rate of 37 per 1000 women while the latter, where abortion is available upon request, have a rate of 34 per 1000 women.
