Despite the advancements in medical technology, unsafe abortion is common worldwide and it is estimated that about 13% of maternal deaths occur each year due to unsafe abortion predominantly in developing countries. However, since 1990, substantial global progress has been made to address various causes of maternal death including severe bleeding, hypertensive disorders of pregnancy and obstructed labor. On the contrary there has been minimal efforts in addressing the risks associated with unsafe abortion though highly preventable. The high prevalence is owed to a lack of awareness on safe abortion practices, desire for educational pursuit and poor use of contraceptives that lead to unplanned pregnancy. In attempting unsafe abortion, early health complications such as infection, hemorrhage, injury to internal organs, infertility and post abortion stress disorders are seen as long-term complications. Thus, mass education on contraceptives is highly needed to protect mothers from death due to unsafe abortion.

Keywords: unsafe abortion, unplanned pregnancy, contraceptives, maternal death

Unhealthy habits are far from being dearth in recent times. One of such very common habits is unsafe abortion. The World Health Organization (WHO) defines unsafe abortion as a procedure of pregnancy termination either by persons lacking the necessary skills or in an environment that does not conform to minimum standards or both.¹ Unsafe abortion though highly preventable, remains one of the five leading causes of maternal death after hypertensive disorders of pregnancy, severe bleeding, puerperal sepsis, and obstructed labor.² According to the World Health Organization (WHO) abortion is considered safe when performed using a method that is appropriate for gestational age and by trained health professionals in a safe and clean environment.³ Despite the advancement in medical technology and availability of legal abortion services in some countries such as Canada, women still obtain and use unsafe abortion to terminate pregnancy, hence contribute to an increasing rate of maternal mortality.⁴ The increasing rate is attributed to complications such as perforation, sepsis and severe bleeding that occur during unsafe attempts to induce abortion. This commentary aims at discussing the burden of unsafe abortion, causes and effects of unsafe abortion, as well as suggest preventive measures in order to protect mothers from complications including death.

Magnitude of the problem of unsafe abortion

Global estimates state that 210 million women become pregnant each year of whom 80 million pregnancies are unplanned. Out of these 46 million pregnancies are terminated with 19 million being through unsafe practices.⁵ More than 98% of unsafe abortion occur in developing countries and World Health Organization (WHO) estimates that 1 in 10 pregnancies end up with unsafe abortion. Likewise, 68,000 women die due to unsafe abortion each year.^5,6 In developing countries, about 220 women die per 100,000 due to unsafe abortions, and in sub-Saharan Africa, mortality from unsafe abortion is 520 per 100,000 cases, Africa bears a disproportionate burden of death from unsafe abortion, accounting for 62% of global death.²  Women who undergo unsafe abortions have a 7% risk of experiencing life threatening complications while most of the deaths occur in places with strict laws prohibiting abortion.^1,6 The mean age group is 25-34 years followed by 15-24 according to a study conducted in 2018 in Nepal.⁷

Factors associated with unsafe abortion

Lack of knowledge of safe abortion practices is documented as a factor that accelerate the rate of unsafe abortion, due to the fact that abortion is highly prohibited in numerous countries and education on safe abortion practices is not provided to the community hence increases the rate of unsafe abortion. Also, stigma of unplanned pregnancy influences the decision to terminate the pregnancy especially to unmarried women, and prohibition of the act in numerous countries is also documented as a factor that increase the rate and prevalence of unsafe abortion.¹

Low socio-economic status serves as a barrier for child upbringing since young women with unfavorable economic condition are more likely to abort a pregnancy than those with favorable economic condition, child spacing and desire for educational pursuit can be identified as factors that accelerate the rate of unsafe abortion, for example abortion is highly needed in a condition where there is short interval between birth and another pregnancy or a women is not fully recovered to bear another pregnancy but due to prohibition of the act in numerous countries women tends to use unsafe means to terminate the pregnancy rather than seeking for professional help.⁸ A poor knowledge on proper contraceptive methods leads to undesired pregnancy and lastly trigger unsafe means to terminate pregnancy. Also, Unwanted child is also documented as main cause of unsafe abortion in the context of undesired gender or couples not out for further children and abortion being considered illegal.⁷

Consequences of unsafe abortion

Severe hemorrhage, sepsis, uterine perforation, or damage to internal organs are identified as immediate complications due to unsafe abortion.⁶ Such cases require urgent hospital care for blood transfusion, major reparative surgery, and complete or incomplete hysterectomy which corresponds to the surgical and irreversible removal of the uterus if urgent hospital care is not given. In some cases, death becomes inevitable as a result of the severity of the complications. Also, small bowel can descent and bulge into the vaginal, a rare severe complication of unsafe abortion that can occur following a medical procedure called dilatation and curettage when done by unskilled practitioner if emergency surgical care that including laparotomy is not given death become inevitable.^6,9

Meanwhile, in the long term, Severe anemia, infertility, and death are some long-term effects of unsafe abortion. If severe bleeding is not well managed on time, hemorrhagic anemia becomes inevitable. Also, infections induced by the act can affect the reproductive tracts and cause infertility.⁸ From a financial lens, complications of unsafe abortion need prompt medical attention which women with low socioeconomic status are somewhat deprived from in developing countries. This financial handicap leads to delay in intervention and puts the family under pressure hence, accounts for increased family debts and risk of maternal death.¹⁰ Psychological effects are also identified as an integral effect of unsafe abortion such as post-traumatic stress disorder. Females who have undergone abortion may still have internal conflicts that persist throughout their life due to reasons for abortion, religious and cultural factors that shape women’s attitude.¹¹

Ways of preventing unsafe abortion

Improving knowledge through training and recycling of health workers about prevention and risk factors of unsafe abortion will bridge the gap as health workers can utilize this knowledge for increasing awareness among reproductive age group females.¹² Also, mass education on the use of contraceptives to prevent unwanted pregnancies is an effective means to prevent unsafe abortion. This is so as women who don’t practice family planning have an increased tendency of undergoing unsafe abortion secondary to unplanned pregnancy.¹³ Also, safe legal abortion and post-abortion care which include treatment of complications, contraceptive and family planning services, reproductive and other health services, community and service provider partnerships, and counseling, are key ways of preventing complications that may arise due to unsafe abortion. In a condition where abortion is necessary to save the life of the mother, this act and care will serve to mitigate associated morbidity and mortality of unsafe abortion.¹⁴

Several factors are responsible for unsafe abortion worldwide, including lack of knowledge on safe abortion services, stigma of unplanned pregnancies and desire to bear children only after marriage. Hence it is recommended that modern contraceptive and safe abortion services should be made available and easily accessible to women who need these services in the context of a health emergency. Public awareness should be intensified to destigmatize abortion care seeking. Also, further research is required in order to understand why the prevalence of unsafe abortion is high in developing countries despite the advancement in medical services over the years.

Department of obstetrics and gynecology saint Francis university college of health and allied sciences.

Authors have none to declare and no one eligible for authorship has been excluded.

Not required.

No funding was obtained for this paper.

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