The World Health Organization (WHO) released a new report in March documenting that the number of women dying from unsafe abortions worldwide has declined significantly over the last two decades. This welcome news is consistent with last year’s much-publicized studies from the United Nations (UN) and the Institute for Health Metrics and Evaluation regarding an overall drop in maternal deaths. Still, maternal mortality remains a serious global problem, and unsafe abortion is undeniably one of the main causes of maternal mortality. Yet, that reality could easily be missed by looking at recent policies to address maternal health. Despite the international community’s growing attention to and resources for maternal health, many leading advocates, policymakers and donors—including the United States—are reluctant to even acknowledge the role of unsafe abortion in maternal mortality, much less address it directly.

Rates, Causes and Consequences

WHO defines unsafe abortion as a procedure for terminating an unintended pregnancy performed by persons lacking the necessary skills, in an environment that does not conform to minimal medical standards, or both.¹ Thus, for example, unsafe abortions include those performed by unskilled providers under unhygienic conditions, those that are self-induced by a woman inserting a foreign object into her uterus or consuming toxic products, and those instigated by physical trauma to a woman's abdomen. Women die from unsafe abortion usually by suffering from severe infections, bleeding caused by the procedure or organ damage.

According to WHO, unsafe abortion is one of the three leading causes of maternal mortality, along with hemorrhage and sepsis from childbirth.¹ The good news is that deaths from unsafe abortion worldwide have dropped from 69,000 in 1990 to 47,000 in 2008, paralleling the one-third cut in maternal mortality from 546,000 deaths in 1990 to 358,000 in 2008. The bad news is that the proportion of women dying from unsafe abortion has remained stagnant at approximately 13% of maternal deaths, even though deaths from unsafe abortion can largely be prevented. Moreover, the sheer number of unsafe abortions worldwide jumped from 19.7 million in 2003 to 21.6 million in 2008, following growth in the overall population of women of childbearing age. Unless strategies to address unsafe abortion are implemented, these numbers are likely to keep rising.

In particular, two key factors impact unsafe abortion rates: access to contraceptives and to safe abortion services. Extensive research shows that behind almost every abortion is an unintended pregnancy, and the most effective way to prevent unintended pregnancy is through correct and consistent use of contraceptives. Data from the Guttmacher Institute document that 40% of the 185 million pregnancies in the developing world in 2008 were unintended, and that about half of them—or almost one in five of all pregnancies—ended in abortion.² In addition, four in five unintended pregnancies in the developing world occurred among women with an unmet need for modern contraceptives. And, around the world, abortion rates are lowest in subregions where contraceptive use is high.

But because contraceptives are not always used correctly or consistently, and because no method is 100% effective, family planning services cannot be relied on as the sole strategy for preventing unsafe abortions. Access to safe abortion is also important. The evidence is clear that where abortion is legal on broad medical and social grounds, and widely accessible through the formal health system, it is highly safe; where it is illegal and clandestine, it is very often unsafe. Women confronting unplanned and unwanted pregnancies in countries where legal abortion is not available still resort to abortion. In fact, the abortion rate (the number of abortions per 1,000 women aged 15–44) is similar in regions where legal abortion predominates and in regions characterized by highly restrictive abortion laws. In other words, legal restrictions on abortion largely do not affect whether women will get an abortion, but they can have a major impact on whether abortion takes place under safe or unsafe conditions and, therefore, whether it jeopardizes women's health and lives.

Failure to recognize and address the fundamental causes and consequences of unsafe abortion takes its greatest toll on the poorest women, because almost all maternal deaths globally from unsafe abortions take place in developing countries. Additionally, five million women a year are treated for serious health complications from unsafe abortion procedures that can lead to long-term consequences such as infertility.² Unsafe abortion endangers the security of an entire household, and places children's well-being at risk when their mothers are disabled or killed. There is also an economic toll on countries, which includes the strain on under-resourced government health facilities and the accumulation of lost productivity.

The Global Response

Efforts to reduce maternal mortality and morbidity have long lagged behind other global health priorities. This neglect, however, began reversing course several years ago, and substantially changed over the last year. Several high-profile policies, programs and initiatives now exist to tackle maternal mortality and morbidity worldwide. Yet, many of these efforts fail to address the role of unsafe abortion in maternal deaths and complications, and even fewer take a comprehensive approach to the problem. Such an approach would have three elements. As noted, the first two are access to family planning services and provision of safe abortion care. The third, and the least controversial, is promotion of emergency or postabortion care to treat complications of incomplete or unsafe abortions.

The UN Millennium Development Goals (MDGs) are the overarching development paradigm that guides most global efforts to combat poverty and improve health. Within this framework, MDG 5 seeks to improve maternal health and identifies several targets and indicators to achieve this goal, including achieving universal access to reproductive health and addressing the unmet need for family planning. There is nothing, however, in MDG 5 specific to the prevention of unsafe abortion.

In recognition of the slow pace of progress on MDG 5 relative to other MDGs, the UN Secretary-General in 2010 unveiled a new global strategy for women's and children's health. This strategy stands out among other key maternal and child health initiatives that have been recently proposed by virtue of its explicit support for a "comprehensive, integrated package of essential interventions and services."³ This package of guaranteed benefits is described to include "family-planning information and services, antenatal, newborn and postnatal care, emergency obstetric and newborn care, skilled care during childbirth at appropriate facilities, safe abortion services (when abortion is not prohibited by law), and the prevention of HIV and other sexually transmitted infections." It must be noted, however, that because the Secretary-General's strategy is not based on country consensus and is not negotiated by member countries, unlike other UN agreements such as the MDGs, it is not viewed by many as carrying the same authority as other UN documents or policies.

In contrast to the Secretary-General's strategy, other prominent global efforts to reduce maternal mortality have remained silent on the subject of unsafe or safe abortion. For example, the 2010 G-8 governmental summit in Canada identified maternal and child health as a development priority when it launched the Muskoka Initiative to achieve MDGs 4 (on child mortality) and 5. The initiative specified its promotion of "comprehensive, high impact and integrated interventions," which would include "antenatal care; attended childbirth; post-partum care; sexual and reproductive health care and services, including voluntary family planning."⁴

Likewise, the International Alliance for Reproductive, Maternal and Newborn Health— a public-private partnership announced last fall that consists of the U.S. Agency for International Development (USAID), the United Kingdom's Department for International Development (DFID), the Australian Agency for International Development (AusAID) and the Bill & Melinda Gates Foundation—identifies its goals as reducing the unmet need for family planning, expanding skilled birth attendance and facility-based deliveries, and increasing the number of women and newborns receiving quality postnatal care, all to accelerate progress for those aspects of MDGs 4 and 5 that have been lagging.⁵

Another important combined governmental and nongovernmental collaboration, however, does acknowledge the problem of unsafe abortion, although it has moved cautiously into this issue. Established in 2005, the Partnership for Maternal, Newborn and Child Health seeks to further progress on MDGs 4 and 5, and represents multilateral and UN agencies, donors, partner countries and civil society organizations. It promotes a continuum of care approach to maternal health, which its 2009 consensus statement lists as including comprehensive family planning services and safe abortion services where legal.

Meanwhile, the global community of nongovernmental organizations (NGOs) working on maternal mortality also lacks unity in its approach to unsafe abortion. Certain leading maternal health groups, such as Family Care International and Women Deliver, have been outspoken champions of evidenced-based policies that support safe abortions services to reduce maternal mortality. On the other hand, the White Ribbon Alliance for Safe Motherhood—an international coalition of individuals and organizations—affirms the use of family planning as a critical intervention to reduce maternal deaths in its publications and occasionally references unsafe abortion as a cause of maternal mortality, but remains conspicuously silent in the public debate on the role of safe abortion in preventing maternal deaths and disabilities.

In short, policymakers and advocates are increasingly willing to promote family planning as a key intervention in promoting maternal health, but the discussion of unsafe abortion remains limited, and that of safe abortion, decidedly taboo.

The U.S. Approach

There is no doubt that the Obama administration has a serious commitment to issues of maternal health. Maternal and child health, along with family planning and reproductive health, are two of the key pillars of its Global Health Initiative. And in its FY 2012 budget, the administration requested $846 million for global maternal and child health programs—a 54% increase from FY 2010 funding levels and a $146 million increase from the FY 2011 request—which is a meaningful endorsement in the current and contentious fiscal environment.

Nonetheless, the United States has, at best, a mixed record in its approach to the pressing problem of maternal health. A comprehensive approach would encompass the three prongs of provision of family planning services, access to safe abortion care and delivery of postabortion care. On the front end, the United States is the world's leading donor in supporting family planning programs. On the back end, USAID's family planning and reproductive health program also supports access to postabortion care, although only partially. However, the United States does not work at all on the controversial middle prong of provision of safe abortion services.

Granted, USAID is severely constrained by the 1973 Helms amendment to the Foreign Assistance Act, which prohibits any U.S. foreign aid to be used for "abortion as a method of family planning." But a strong argument can be made that the Helms amendment has been interpreted too strictly and has had an inappropriate chilling effect on activities in which USAID could and arguably should be engaged. In particular, USAID's postabortion care program has been limited by its resistance to purchasing life-saving equipment such as manual vacuum aspiration kits for treatment of incomplete abortions. Overinterpretation of the Helms amendment has also kept USAID from providing abortion services in situations that are exempted under the prohibition—that is, abortions to save the life of the woman or in cases of rape or incest.

European Donors Lead the Way

While the United States has been bogged down for decades by political fighting over abortion—which has extended into family planning and reproductive health assistance and policy—leading European donors have increasingly become forthright and dedicated defenders of the full spectrum of sexual and reproductive health and rights. Countries that have supported foreign assistance specifically for abortion include Denmark, Finland, the Netherlands, Norway, Sweden and the United Kingdom.

Among these, the United Kingdom has played a critical and leading role in its policy and programmatic efforts. In 2006, it established the Safe Abortion Action Fund (previously the Global Safe Abortion Fund), administered by the International Planned Parenthood Federation, to respond to the upheaval caused by President George W. Bush's reinstatement of the Mexico City Policy, also known as the global gag rule. The gag rule cut off U.S. family planning funding to foreign NGOs that engaged in any abortion-related services or advocacy with their own, non-U.S. funding, leaving many of the biggest and most effective providers of family planning and reproductive health services without a significant source of assistance. The Safe Abortion Action Fund provides resources to NGOs that work on safe abortion. It has been supported by different European countries over the last few years, and is currently receiving funding from the United Kingdom and Norway.

Of particular note is the United Kingdom's unapologetic policy position on safe and unsafe abortion. A 2010 DFID position paper on the subject notes: "Our position is that safe abortion reduces recourse to unsafe abortion and thus saves lives, and that women and adolescent girls must have the right to make their own decisions about their sexual and reproductive health and well being."⁶ It is also remarkable that Secretary of State for International Development Andrew Mitchell, a member of the Conservative party, has been publicly vocal in his support for family planning, maternal health and abortion in DFID's foreign assistance program.

Other European nations also have shown strong dedication to safe abortion care and rights. Sweden has taken an unequivocal and outspoken leadership role in its support for safe abortion throughout its various development policies, and it prioritizes emergency obstetric care and comprehensive abortion care as key interventions to decrease maternal mortality. The Dutch have recently awarded a large grant on safe abortion work through its Choices and Opportunities Fund, which disburses 40 million euros for sexual and reproductive health and rights work. Norway has employed forceful rhetoric to uphold safe abortion rights: In its Action Plan for Women's Rights and Gender Equality in Development Cooperation, it promises to "raise controversial issues" and advocate for the decriminalization of abortion so that women who have abortions can seek safe treatment and to fight for the "right to safe abortion on demand."⁷ Finally, Finland, as part of its development policy on sexual and reproductive health and rights, recognizes that sexual and reproductive health includes the option for safe abortion and that unsafe abortions are a major aspect of maternal deaths.⁸

Although European involvement in and support for safe abortion is critically important, the absence of other key global players creates a significant barrier to coordinated and effective global health efforts to combat maternal deaths and disability. The link between prevention of unsafe abortion and the prevention of maternal mortality is being made—at least in fits and starts—among some NGOs, donor countries and multilateral agencies. The rest of the world, including the United States, however, needs to catch up.

REFERENCES

1. WHO, Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2008, sixth ed., 2011, <http://whqlibdoc.who.int/publications/2011/ 9789241501118_eng.pdf>, accessed May 5, 2011.

2. Guttmacher Institute, Facts on induced abortion worldwide, In Brief, 2011, <http://www.guttmacher.org/pubs/fb_IAW.html>, accessed May 5, 2011.

3. UN Secretary-General, Global Strategy for Women's and Children's Health, 2010, <http://www.un.org/sg/hf/Global_StategyEN.pdf&gt;, accessed May 5, 2011.

4. G8, G8 Muskoka Declaration: Recovery and New Beginnings, 2010, <http://canadainternational.gc.ca/g8/assets/pdfs/2010- declaration_eng.pdf>, accessed May 5, 2011.

5. USAID, International Alliance for Reproductive, Maternal, and Newborn Health, no date, <http://www.usaid.gov/our_work/global_ health/pop/alliance.html>, accessed May 5, 2011.

6. DFID, Safe and Unsafe Abortion: Practice Paper, 2010, accessed May 5, 2011.

7. Norwegian Ministry of Foreign Affairs, Action Plan for Women's Rights and Gender Equality in Development Cooperation, 2007–2009, 2007, <http://www.regjeringen.no/upload/UD/Vedlegg/Utvikling/ ActionPlanwomensRights.pdf>, accessed May 5, 2011.

8. Ministry for Foreign Affairs of Finland, Freedom to Choose: Sexual and Reproductive Health and Rights in Finland's Development Policy, 2010, <http://formin.finland.fi/public/default.aspx?contentid=193411&gt;, accessed May 5, 2011.