Chapter 1. Introduction
Background and context (1.1)
Sexual and reproductive health is fundamental to individuals, couples and families, and to the social and economic development of communities and nations (1). As provided in the Constitution of the World Health Organization (WHO), the organization’s objective is “the attainment by all peoples of the highest possible level of health”, and to fulfil that objective, WHO’s functions include providing technical assistance to countries in the field of health (2, Articles 1 and 2). Universal access to sexual and reproductive health (SRH) information and services is central to both individual and community health, as well as the realization of human rights, including the right to the highest attainable standard of SRH (3). In addition, the increased SRH risks in humanitarian settings, including armed conflict, require specific attention from a human rights perspective (4 [para. 7], 5, 6 [paras 19-24]).
Since the start of the COVID-19 pandemic and based on lessons learnt from previous disease outbreaks – when SRH services have been severely disrupted, causing individuals to feel disempowered and be exposed to preventable health risks – WHO has included comprehensive abortion care in the list of essential health services in certain recent technical publications and guidance (7-12). Abortion care encompasses management of various clinical conditions including spontaneous and induced abortion (of both non-viable and viable pregnancies) and intrauterine fetal demise, and also post-abortion care, including management of incomplete abortion. Strengthening access to abortion care within the health system is fundamental to meeting the Sustainable Development Goals (SDGs) relating to good health and well-being (SDG3) and gender equality (SDG5) (13). WHO’s Global Reproductive Health Strategy, which seeks to accelerate progress towards achievement of international development goals, identifies elimination of unsafe abortion as a priority mandate (1). The importance of quality abortion care to health is similarly underscored by the United Nations Global Strategy for Women’s, Children’s and Adolescents’ Health, which includes evidence-based interventions for abortion and post-abortion care as one effective way to help individuals thrive and communities transform (14).
Quality abortion care is foundational to this guidance. Quality of care (see Glossary) encompasses multiple components: effectiveness, efficiency, accessibility, acceptability (e.g. patient centred), equity and safety. Effective care includes the delivery of evidence-based care that improves the health of individuals and communities, and is responsive to their needs. Efficient care optimizes resource use and minimizes waste. Quality abortion care must be both accessible (timely, affordable, geographically reachable, and provided in a setting where skills and resources are appropriate to medical need) and acceptable (incorporating the preferences and values of individual service users and the cultures of their communities). It is imperative that abortion care is equitable, and that health care does not vary in quality based on the personal characteristics of the person seeking care, such as their gender, race, ethnicity, socioeconomic status, education, if they are living with a disability, or based on their geographic location within a country. And finally, quality abortion care implies that it is safely delivered and minimizes risks and harms to service users (15). Underpinning these components is the principle that provision of quality abortion care would be in compliance with human rights.
Globally, abortion is a common procedure, with 6 out of 10 unintended pregnancies and 3 out of 10 of all pregnancies ending in induced abortion (16). When abortion is safe – defined as being carried out using a method recommended by WHO, appropriate to the gestational age, and by someone with the necessary skills (17) – the risks are very low. However global estimates demonstrate that 45% of all abortions are unsafe, including 14.4% considered to be “least safe” (18). This is a critical public health and human rights issue; unsafe abortion is increasingly concentrated in developing countries and among groups in vulnerable and marginalized situations. In countries where induced abortion is highly restricted by law or unavailable due to other barriers, safe abortion has often become the privilege of the rich, while poor women have little choice but to resort to the services of unskilled providers in unsafe settings, or induce abortion themselves often using unsafe methods, leading to deaths and morbidities that become the social and financial responsibility of the public health system, and denial of women’s human rights. The legal status of abortion has no effect on a woman’s likelihood of seeking induced abortion, but it dramatically affects her access to safe abortion (19).
Between 4.7% and 13.2% of all maternal deaths are attributed to unsafe abortions (20, 21). This equates to between 13 865 and 38 940 lives lost annually, due to the failure to provide safe abortion, with many more experiencing serious morbidities. Developing countries bear the burden of 97% of unsafe abortions (18). The proportion of abortions that are unsafe is also significantly higher in countries with highly restrictive abortion laws than in those with less restrictive laws (18). Over half (53.8%) of all unsafe abortions occur in Asia (the majority of those in south and central Asia), while another quarter (24.8%) occur in Africa (mainly in eastern and western Africa), and a further fifth (19.5%) in Latin America and the Caribbean (18). The subregions where the highest proportions of abortions have been categorized as “least safe” are northern, eastern, western and middle Africa (approximately 45–70% of all abortions are “least safe”), followed by the Caribbean, Oceania and Central America (approximately 25–30% of all abortions are “least safe”) (18). A review of facility-based treatment for complications of unsafe abortion in 26 developing countries in 2012 indicated that 7 million women were treated in developing countries for complications of unsafe abortion that year – a rate of 6.9 per 1000 women aged 15–44 years (22).
Abortion, using medication or a simple outpatient surgical procedure, is a safe health-care intervention, when carried out with a method appropriate to the gestational age of pregnancy and – in the case of a facility-based procedure – by a person with the necessary skills. In these circumstances, complications or serious adverse effects are rare. Medical abortion has revolutionized access to quality abortion care globally. Studies have demonstrated that medicines for abortion can be safely and effectively self-administered outside of a facility (e.g. at home). Individuals with a source of accurate information and access to a trained health worker (in case they need or want support at any stage of the process) can safely self-manage their abortion process in the first 12 weeks of gestation. Service delivery with minimal medical supervision can significantly improve access, particularly in restricted settings and crisis situations, as well as improve privacy, convenience and acceptability of the abortion process without compromising safety and effectiveness (23). However, in both low- and high-resource settings, law, policy and practical barriers can make it difficult to access quality abortion care. Multiple actions are needed at the legal, health system and community levels so that everyone who needs it has access to comprehensive abortion care (CAC), i.e. information, abortion management (including induced abortion, and care related to pregnancy loss/spontaneous abortion) and post-abortion care.
- When considering the concept of “essential health services”, it is important to note that different areas, even within the same country, may require different approaches to designate essential health services and to reorient health system components to maintain these services (7). ↩
- Unsafe abortion refers to abortion when it is carried out by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. ↩