Regional differences in unsafe abortion

Safe and unsafe abortions are not homogeneously distributed throughout the different regions of the world. Developed countries make up more than 20% of the world’s population, but only half a million of the almost 20 million unsafe abortions performed worldwide annually take place in these regions of the world. This occurs because abortions in developed countries are mostly legal and safe, whereas abortions in developing countries, with the exception of China and a few other countries, are mostly illegal and unsafe. India is another densely populated country where abortion is legal; however, in India a large proportion of induced abortions are still performed in unsafe conditions outside the official health-care system.

The most recent estimates of unsafe abortion rates by region refer to 2003 and show that the highest rates per 1000 women of 15–49 years of age are found in Africa and Latin America (29/1000), followed by Asia (11/1000), the rate for Asia being influenced by the inclusion of China. Considering subregions within each continent, the highest rate is found in Eastern Africa (39/1000), followed by South America (33/1000) and Western Africa (28/1000), Central Africa (26/1000), Central America (25/1000)and Southeast Asia (23/1000). The rate of unsafe abortion in the more developed regions is only 2 per 1000.

Why unsafe abortion is still so prevalent in the world?

This is in fact three different questions. First, we have to ask why women get pregnant if they do not intend having a baby. The second question is, once they are pregnant then why is that pregnancy so unwanted that women choose to subject themselves to all the risks and suffering associated with unsafe abortion in societies where the practice is legally restricted or where safe abortion is of difficult access. Finally, the third question is why an abortion, which is one of the surgical or medical procedures with the lowest risk, should become risky or unsafe. We will try to answer each of these questions ahead.

Why unsafe abortion is still so prevalent in the world?

This is in fact three different questions. First, we have to ask why women get pregnant if they do not intend having a baby. The second question is, once they are pregnant then why is that pregnancy so unwanted that women choose to subject themselves to all the risks and suffering associated with unsafe abortion in societies where the practice is legally restricted or where safe abortion is of difficult access. Finally, the third question is why an abortion, which is one of the surgical or medical procedures with the lowest risk, should become risky or unsafe. We will try to answer each of these questions ahead.

Why women get pregnant if they do not intend having a baby

The most common reason women give for having an unintended or unwanted pregnancy is that they lack information about contraceptive methods or do not know how to access them. Another important cause of unwanted pregnancy is the woman’s inability to exercise control over when and under what circumstances she will have sexual intercourse.

Each of these circumstances leading to abortion merits a more detailed discussion to fully understand its significance, thereby enabling practical interventions that may contribute towards preventing unsafe abortions to be proposed.

Lack of knowledge about contraceptive methods

Many women became pregnant against their will because they lack accurate information on how to prevent pregnancy. According to the Demographic and Health Surveys (DHS), a high proportion of women worldwide state that they have knowledge of at least one ‘modern’, highly effective contraceptive method, which includes all kinds of hormonal methods, intrauterine devices (IUDs), barrier methods such as the diaphragm and the male or female condom, and male or female surgical sterilisation.

Examining the data from the most recent DHS, there were very few countries in which less than 90% of the women interviewed declared knowledge of at least one of these methods. The lowest percentage was found in Chad with less than 50% and in Mali with less than 75%. Knowledge of modern contraceptives is rapidly increasing in other less developed countries such as Mozambique, Guinea and Madagascar. While only 60–70% of women had known of at least one modern contraceptive in the previous DHS, over 90% declared that they knew of one such in the surveys carried out between 2003 and 2004.

The percentage of women with knowledge of modern contraceptives reaches virtually 100% not only in developed countries but also in some less developed countries such as Bangladesh, the Dominican Republic and Brazil.

These studies also show significant differences within each country, according to place of residence and socioeconomic status. The number of years of schooling is the main determinant of contraceptive knowledge. In almost every less developed country, 99% or more of women with secondary education or more declared knowing of at least one modern contraceptive method, while only 75% or less of women with no education in Cameroon and Bolivia knew of at least one modern contraceptive.

The difference may be even greater depending on how ‘knowledge’ of a method is defined. In the DHS, each method is named and the woman being interviewed states if she knows about it. This means that any woman who has heard of a method is included as ‘knowing about’ the method. It may be that her ‘knowledge’ is completely wrong. The information she ‘knows’, may be erroneous; she may have heard, for instance, that the IUD causes an abortion every month or that the pill causes infertility. Such false rumours may prevent women from using these methods.

Studies that have investigated the accuracy of knowledge about contraceptive methods have shown discouraging results. A study carried out in the slums of Rio de Janeiro showed that 23% of women who used contraceptive pills were using them incorrectly. Other studies have shown that adolescents and women with little education who attempt to use periodic abstinence for fertility control do so with no accurate knowledge of the menstrual cycle or the fertile period. The basic knowledge of reproductive physiology among adolescents in some less developed countries may be so poor that they are unaware that girls are able to become pregnant the first time they have sexual intercourse.

Inadequate knowledge about contraception may affect the ability of women to protect themselves against unintended pregnancies in at least two ways: (1) they may opt not to use a method, incorrectly believing that it may have a negative effect (e.g., that IUDs cause cancer or that the pill causes infertility); and (2) they may use it incorrectly, inadvertently exposing themselves to the risk of pregnancy. As for knowledge of contraceptives in general, the accuracy of information is affected by education level, increasing the social disadvantage of women who have less opportunity to attend school.

In addition, sensationalist information often disseminated by the media about certain methods may have an impact on the number of abortions, even in developed countries. A good example was the reported increase in the risk of adverse vascular effects associated with the third-generation pill, depicted in the media as constituting a very significant risk. An evaluation conducted in Norway showed a subsequent dramatic decrease in the use of this method, which coincided with a 36% rise in the abortion rate among 15–24-year-old women.

Lack of access to contraceptive methods

The best indicator of access to contraceptive methods is the unmet need for contraceptives. ‘Unmet need’ is defined as the proportion of women who do not want to get pregnant at that precise time or ever again and who are not using any contraceptive method. It has been estimated that 125 million women have unmet needs for family planning, mostly in the developing countries.

Looking at the unmet need for contraceptive methods in less developed countries, there would appear to be three stages. The first stage, in which the desire for fertility regulation is low and contraceptive use is therefore also very low, results in minimal unmet need. In the second stage, a higher percentage of women want to control their fertility and access to contraceptive methods varies widely. The highest proportion of women with an unmet need for contraception is to be found in this stage. Finally, in the third stage, the percentage of women who want to control their fertility is highest, as is their access to modern contraceptive methods. At this stage, typical of developed countries, the proportion of women with an unmet need is low. The high unmet need for contraception in countries in the second stage may be one of the main factors that determine the prevalence of unsafe abortion. A study in Nepal found, for example, that for many women unsafe abortion was the only available method of fertility control. Several factors contribute to unmet need: lack of knowledge, lack of availability of contraceptive methods and lack of the resources needed to obtain contraceptives; however, opposition from a partner and family or cultural pressure towards high fertility represent additional factors. Whatever the reason for the unmet need, it will be closely associated with unwanted pregnancy and consequently with abortion.

The highest abortion rates are observed in countries in Eastern and Central Europe that belonged to the former Soviet Union. Contraceptive prevalence was low because access to modern contraceptives was limited and there were legal restrictions to surgical sterilisation. The only easily accessible option for fertility control was abortion. Access to contraception has improved over the past 15 years. As a result, the abortion rate fell rapidly from about 91 per 1000 women of reproductive age in 1995 to just less than 50% of that figure, 45 abortions per 1000 women, in 2003. This is an excellent example of the effectiveness of improved access to contraception as a means of reducing abortion rates.

Failure of contraceptive methods

The use of contraceptives does not guarantee that a woman will not become pregnant. Methods fail because they are not infallible or because they are used improperly. The high failure rate of traditional methods such as periodic abstinence and coitus interruptus is more often the result of improper use than of the intrinsic ineffectiveness of the methods.

Similarly, although the effectiveness of the birth control pill is close to 100% in controlled clinical studies, the failure rates observed in population-based studies are closer to 8% per year of use. Several studies have shown that many pill users have not been instructed on proper use, frequently forget to take it or delay the initiation of a new cycle if they are away from their partner at the time. Most pill users are unaware that the chances of failure greatly increase if the pill-free interval is prolonged for even a few days.

There are virtually no user failures for methods that do not depend on user compliance, such as the Copper-T 380 and progestin-releasing IUDs and implants, which are among the most effective contraceptives available.

Lack of control in sexual relationships

Often women know about and have access to contraceptive methods but do not have control over their use every time they have sexual intercourse. In addition, they may not be using a method because they are not having sexual intercourse and are then unexpectedly forced to have sex without the means with which to protect themselves or the time in which to do so.

Far from being a rare event, sex against a woman’s will is a rather common occurrence. Studies on sexual violence show a prevalence that varies from less than 10% to about 40% of women of childbearing age. The differences in prevalence appear to be related as much to social distinctions between populations as to the various methods used to obtain the information and the different definitions of sexual violence.

Most studies are limited to the occurrence of rape, which is defined as imposed sexual intercourse using force or the threat of force. Their data do not include sexual coercion in exchange for obtaining or maintaining a job, passing an exam or satisfying other personal needs. Coercion is a much more frequent way of imposing sex than rape; however, the more subtle cultural imposition of unwanted sex and a woman’s inability to make use of available protection during desired sex are even more relevant in determining unplanned pregnancy.

In a study carried out in one of the most developed regions of Brazil, 30% of the women interviewed reported having had sex physically imposed on them or having been coerced into sex, and an additional 32% reported having had sex against their will because they felt obliged to comply with their partner’s desire.

Most studies also show that both adolescent and adult males believe that protection against pregnancy is the sole responsibility of the woman. A study conducted in India among women who requested legal termination of pregnancy found that one-third of unwanted pregnancies could be attributed to the husband’s unwillingness to use contraception or to improper or irregular condom use.

Why is a pregnancy so unwanted that it ends in abortion?

No woman takes pleasure in having an abortion. For the majority of women, it is a very disturbing experience that they would much prefer to avoid. Women interviewed following a voluntary termination of pregnancy stated that they had been opposed to abortion until they had to face the choice between aborting and giving birth to an unwanted child. Many, however, continued to oppose abortion under any circumstances.

The most common reasons for women to decide to terminate a pregnancy can be grouped as follows: absence of the father, financial constraints, the inability to provide good parenting or interference with life prospects, conflict with prevailing social norms, health concerns and a lack of social support.

The absence of the father

The lack of a functional family unit or the absence of a partner who would assume his role as a father is a strong motivation to abort. This happens not only among young, unmarried women but also among older women who may have been abandoned by a partner or may be in an unstable partnership.

Financial constraints

The lack of financial resources to support a future child or sufficiently care for existing children is a frequently declared reason for aborting. In fact, this financial insecurity is no more frequent in the poorest sectors than it is among the middle classes whose expectations for their children’s future gain greater relevance.

Inability to provide good parenting/interference with life prospects

Particularly among adolescents, the feeling that they lack the maturity or preparation for motherhood is often expressed as their motive for seeking an abortion. The belief that pregnancy and motherhood would interfere with education and employment-related life prospects is a common reason for aborting. A study at a Brazilian university showed that 74% of students who became pregnant had abortions, whereas only 36% of female staff members in the same age group aborted their pregnancies. Further analysis of qualitative aspects of the same study showed that the primary reason for aborting was inability to care for or educate the child.

Conflict with prevailing social norms

Newspapers around the world published the story of two women in northern Nigeria, both widows, who had each given birth to a baby, proof of their illicit sexual relationships. They were condemned to death by stoning for the crime of adultery. Women who live in societies with such rigorous restrictions on extramarital sexual activity will often choose to abort a pregnancy that does not comply with the accepted norms.

The situation is not very different in many Western societies with restrictive social norms of their own. Transgressors do not risk being sentenced to death by stoning but they risk other forms of segregation that can destroy their social lives. In Latin America, extramarital childbirth is not socially acceptable among middle- or upper-class families. When there is no hope of arranging a marriage before a pregnancy becomes evident, the only way to preserve both the family’s honour and the social future of the pregnant woman is to abort.