•The four impacts of unsafe abortion
on the health of woman are​

Unsafe abortion is a significant cause of death and ill health in women in the developing world. A substantial body of research on these consequences exists, although studies are of variable quality. However, unsafe abortion has a number of other significant consequences that are much less widely recognized. These include the economic consequences, the immediate costs of providing medical care for abortion-related complications, the costs of medical care for longer-term health consequences, lost productivity to the country, the impact on families and the community, and the social consequences that affect women and families. This article will review the scientific evidence on the consequences of unsafe abortion, highlight gaps in the evidence base, suggest areas where future research efforts are needed, and speculate on the future situation regarding consequences and evidence over the next 5–10 years. The information provided is useful and timely given the current heightened interest in the issue of unsafe abortion, growing from the recent focus of national and international agencies on reducing maternal mortality by 75% by 2015 (as one of the Millennium Development Goals established in 2000).

Keywords economic consequences, maternal morbidity, maternal mortality, postabortion complications, social consequences, unsafe abortion

The WHO defines unsafe abortion as a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both [1]. An estimated 21 million unsafe abortions occur each year, an annual rate of 16 for every 1000 women in the developing world, where the vast majority of unsafe abortions take place [who, 2010, submitted] [2]. Recent work indicates that there has been little decline in this rate between 1995 and 2003, the most recent year for which there are published estimates of the number of unsafe abortions worldwide [3]. Unsafe abortion has gained more attention recently as an important and preventable cause of maternal mortality and morbidity. In light of the worldwide focus on attaining the Millennium Development Goals (MDGs), a broad agenda, agreed by world leaders in 2000, aims to reduce poverty, hunger, disease, illiteracy, environmental degradation and discrimination against women, and more specifically MDG 5, which aims to reduce maternal mortality by 75% by 2015.

  Two fundamental factors that underlie unsafe abortion are poor access to safe and legal abortion services, and unintended pregnancy. A third of the 1.3 billion women (who are 15–44 years of age) in the developing world live in countries where abortion is not permitted for any reason at all or permitted only to save the woman's life, and another 15% are in countries where abortion is permitted only to protect physical or mental health, but where access even under these restrictive criteria is very limited [4]. In addition, 22% of women from developing countries live in India, where despite a liberal law, permitting abortion on socioeconomic grounds, access to safe abortion services is poor, and approximately 60% of abortions in India are considered to be unsafe [3]. Estimates of the level of unintended pregnancy in the developing world are available for 2008. The annual rate of unintended pregnancies was 57 per 1000 women, and 40% of all pregnancies were unintended (~half of these ended as induced abortions) [4].

induced abortions) [4].

Although unsafe abortion is recognized as a significant contributor to mortality and morbidity among women of reproductive age, research on this topic is relatively scarce and the evidence base on the consequences of unsafe abortion is limited [5]. One key constraint concerning research on the consequences of unsafe abortion (and on other aspects as well), is the difficulty of obtaining information that is representative of all women having an abortion, because of the very high level of underreporting of abortion experience in population-based studies that directly interview women [6]. Moreover, the measurement of consequences, other than those that are immediate or very short term, presents the additional difficulty of achieving adequate follow-up on respondents on an especially sensitive topic, compounding the usual demands of achieving a high response rate in longitudinal studies. As a result, much of the available evidence is cross-sectional and facility based, conducted in hospitals or other types of facilities, designs that have the advantage that women who have experienced an unsafe abortion are more easily identified for inclusion in a study, but that have the disadvantage of not representing all women having unsafe abortions, since they exclude women who may need but do not obtain care at such facilities.

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