(October 2005) The ages at which women have unsafe abortions—those abortions performed by unskilled practitioners in unhygienic conditions—differ markedly among regions in the developing world, according to a recent study published in the journal Reproductive Health Matters.1

The report contradicts a common belief that women terminating their pregnancies with unsafe abortions are predominantly the young and unmarried. While 60 percent of African women who have unsafe abortions are under age 25, study co-authors Iqbal Shah and Elisabeth Åhman of the World Health Organization (WHO) found that most of the women having unsafe abortions in Asia are older than age 25 and already have children.

Understanding these disparate age patterns could help in developing programs that reach women most in need of contraceptive services and post-abortion care, say the study’s authors as well as other experts.

“Researchers have felt that these different patterns existed, but they didn’t have the numbers,” says Fariyal Fikree, who is technical director of health communications at the Population Reference Bureau and who has extensively studied abortion in Asia. “Now that they have this data, this helps to identify the women who are getting unsafe abortions so that interventions can be targeted.”

Susheela Singh, vice president for research at the Alan Guttmacher Institute and an international authority on abortion, adds that the report shows “the premarried in all regions, especially Africa, should be targeted.” But she cautions that the study also highlights the needs of married women who want to space births and limit the size of their families.

‘An Urgent Public Health Issue Mired in Political Controversy’

Each year an estimated 46 million pregnancies around the world are terminated through induced abortion, and about 19 million of them occur outside the legal system, according to WHO.2 Most of these illegal abortions are considered unsafe because they are performed by unskilled providers and/or in unsanitary conditions.

WHO estimates that nearly 68,000 women die from complications of unsafe abortion each year. About 99 percent of these women live in developing countries, where abortion is often legally restricted and maternal health care services are lacking.3 In addition to those who die from unsafe abortions, tens of thousands suffer chronic and sometimes irreversible health consequences, including infertility.4

“It’s an urgent public health issue on a mass scale [that] has been mired in political controversy,” says Wendy Chavkin, a professor of clinical population and family health at Columbia University’s Mailman School of Public Health.

The new study says that 25 percent of the unsafe abortions in Africa are among young women still in their teens, compared with 9 percent in this age group in Asia. (The study excludes China, the Koreas, and Mongolia from the region of Asia. In these four countries, abortions are available on demand and generally provided safely.) About 57 percent of unsafe abortions in Africa are among women under age 25, compared with 32 percent in the same age group in Asia. At the other end of the reproductive-age range, women age 30 or older account for 23 percent of unsafe abortions in Africa—but 42 percent of unsafe abortions in Asia (see table).


Estimated Percentages of Unsafe Abortions by Age Group as a Percentage of All Unsafe Abortions in Selected Regions

Age Group
Developing Countries*
Africa
Asia*
Latin America & Caribbean
15-19
14
25
9
14
20-24
26
32
23
29
25-29
25
20
28
25
30-34
19
12
22
16
35-39
11
13
11
40-44

*Excluding China, the Koreas, and Mongolia.
Source: Iqbal Shah and Elisabeth Åhman, “Age Patterns of Unsafe Abortion in Developing Country Regions,” Reproductive Health Matters 12, no. 24 (2004).


Understanding the Patterns in Africa, Asia, and Latin America

The pattern in Africa is consistent with other surveys showing that African women begin having sex at earlier ages than elsewhere, and that much sexual activity among adolescents there is unprotected and occurs before marriage.5 This behavior puts many young women in Africa at high risk of unwanted pregnancy. And because abortion is legally restricted on much of the continent, higher levels of unwanted pregnancies increase the likelihood of unsafe abortions.

“Most young women in Africa don’t have information on contraceptives, or the methods are inaccessible,” explains Shah. While the paper did not look at marital status, Shah adds that many unsafe abortions in Africa are among young unmarried women.

But in Asia, the study finds, unsafe abortion is used more often by women who already have children and who want to limit family size.

Among the three developing regions studied, Asia has fewer legal restrictions on abortion as well as the lowest rate of unsafe abortion. However, even where restrictions are less burdensome in the region, safe abortions are not widely available in Asia for various reasons—including cost, lack of approved facilities, and lack of awareness among women and health providers of the conditions under which abortion can be legally provided.

For Latin America and the Caribbean, the study found that more than one-half of unsafe abortions occur among women who are in their 20s. This pattern, along with a high rate of sterilization among women in the region to end childbearing when their desired family size is achieved, indicates that many Latin American and Caribbean women turn to unsafe abortion to space births.

Opportunities for Interventions

The Guttmacher Institute’s Singh says the study underscores the need for information about contraception, access to family planning to prevent unwanted pregnancies, and services for safe abortion and post-abortion care in all regions of the world, although strategies may differ depending on the age and situation of the women most in need.

For example, sex education programs in schools can provide pregnancy prevention information to adolescents, who tend to have less access to reproductive health care than older and married women. Singh adds, however, that ways must be found to reach young unmarried teenagers who are not in school.

For married women, especially those in urban areas, Singh says that reproductive health care is generally more accessible and may provide an avenue for intervention. But while family planning counseling is well recognized as a key component of post-abortion care to prevent repeat abortions, such services are lacking in many hospitals.

And PRB’s Fikree, a doctor who specializes in OB-GYN and family medicine, says that any counseling intervention must explain to its clients the range of contraceptive methods available and when they should be used; side effects those methods may cause; and use of backup methods (such as emergency contraception) when a contraceptive fails.

Chavkin, who is also an obstetrician and gynecologist at the Columbia University Medical Center, adds that the report highlights the need for a more comprehensive approach to reproductive health.

“This underscores the importance of weaving together contraceptive services with all sorts of other reproductive health services, like money going to AIDS prevention,” she says. “This is true for all regions, but Africa has the biggest concentration of unsafe abortion among the youngest women as well as the highest levels of HIV.”


Deborah Mesce is manager of media programs for PRB’s International Programs.


References

  1. Iqbal Shah and Elisabeth Åhman, “Age Patterns of Unsafe Abortion in Developing Country Regions,” Reproductive Health Matters 12, no. 24 (November 2004, Abortion Law, Policy, and Practice Supplement): 9-17.
  2. Elisabeth Åhman and Iqbal Shah, Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2000, 4th ed. (Geneva: World Health Organization, 2004).
  3. Åhman and Shah, Unsafe Abortion.
  4. World Health Organization, Safe Abortion: Technical and Policy Guidance for Health Systems (Geneva: World Health Organization, 2003).
  5. United Nations Commission on Population and Development, World Population Monitoring 2002— Reproductive Rights and Reproductive Health: Selected Aspects (New York: United Nations, 2003).