Layout

Death and Denial: Unsafe Abortion and Poverty
From choice, a world of possibilities Parliamentary Under-Secretary ofState for International Development Millions of women have no access Access to legal and safe abortion "No woman should anywhere
to reproductive health services; care - as well as to care to have to face death or disability
many more have little or no treat incomplete abortion or for the want of a safe
control in choosing whether to complications from unsafe abortion. Is there anybody who
become pregnant. As a result, abortion - would help save the would disagree with the right
every year, some 19 million lives of thousands of women every of a woman not to die in
women have no other choice than year. It would also provide a vital to have an unsafe abortion. Many opportunity to ensure women can pregnancy? Anybody? No."
of these women will die as a subsequently access family The Rt Hon Hilary Benn, MP, result; many more are permanently planning and contraception to Secretary of State for International injured. Nearly all the women who help avoid repeat abortions.
Development, Countdown 2015, die or are injured are poor and livein poor countries. Punitive legal measures and The Global Roundtable, restricting access to safe abortion London, 2004.
Preventing these deaths and do not reduce the incidence of injuries will not be achieved abortion; they just make it more without stopping unsafe abortions dangerous. The result is that more which cause around 13 per cent women suffer. Not surprisingly, it of all maternal deaths. Virtually all is the poorest women - women the deaths of women from unsafe least able to pay for any minimal abortion are in fact preventable. level of care - who end up paying A woman facing an unwanted the highest price. I welcome this pregnancy should not have to risk report as an important contribution death through having an unsafe to dealing with a subject where rational debate and consideredaction are much needed.
Gareth Thomas
January 2006
"A straightforward public health
problem with a known solution has
been allowed to become the killing
fields of women in developing
countries, particularly Africa."
Fred Sai, Special Adviser to the President of Ghana, speaking on unsafeabortion, Countdown 2015, The Global Roundtable, London, 2004. This year alone, an estimated inequality within societies. It is the Lack of access to modern 19 million women and girls, faced inability of women, especially contraception as a factor driving with unintended and unwanted young women and girls, to fulfil unwanted pregnancies to unsafe pregnancies, will face the deadly their basic sexual and reproductive abortions cannot be ignored.
consequences of unsafe abortion.
rights, and to have control over Nearly 70,000 of these women and their own bodies, which forces There is a pressing need for an girls will die, and hundreds-of- upon them a stark choice - face open and informed discussion to thousands of others will be left social exclusion or risk their lives address the fundamental injustice with debilitating, and frequently and health through unsafe abortion.
of the causes and consequences of lifelong injuries, as a result. Over 96 unsafe abortion. There are few per cent of these women will come During last September's United governments with the courage to from the world's poorest nations.
Nation's World Summit, world take a leadership position on leaders reaffirmed their abortion rights and there are For reasons ranging from human commitment to the Millennium equally few international rights to religion, abortion Development Goals, including the organisations with such courage.
generates more political and social goal of reducing maternal mortality The Government of the United disagreement than almost any and improving maternal health.
Kingdom and IPPF are two of the other subject. It remains a singularly The Summit also reasserted a few that have both the courage emotive and complicated issue in previous global commitment to and the resolve to act in a struggle many countries, at times seemingly achieve universal access to so crucial to women's well-being.
without any room for balanced reproductive health. The review process noted that little progress Through the work of the had been made towards achieving Department for International This report offers an overview of either since the Millennium Development, the United Kingdom the current situation regarding Development Goals were first has promoted an approach to unsafe abortion around the world.
adopted five years ago. It further addressing abortion based on In doing so it seeks to open a highlighted the fact that unsafe sound public health evidence. In much needed and timely debate abortion is a major contributor to doing so, the UK has established among governments, these stubbornly high levels, an international reputation for both parliamentarians, public health, particularly in developing countries.
leadership and wisdom. IPPF is development and medical experts, determined to play a constructive as well as service providers and Extensive independent research role as partner with the Department global advocates for legal and safe shows that restricting access to for International Development in abortion such as IPPF.
abortion does not make it go this undertaking. With upwards of away; it only makes it clandestine 15 per cent of maternal mortality Unsafe abortion is one of the and unsafe. Health authorities directly attributable to illegal and largest contributors to global and political leaders in more and unsafe abortion – perhaps as much maternal mortality: a very more countries are prepared to as 50 per cent in some countries preventable human tragedy that re-examine abortion policy when in Africa and South East Asia – highlights the failure of national they understand how unsafe tackling head-on the reduction governments and the international abortion contributes to maternal and even the elimination of this community to address a public mortality and ill health. Moreover, preventable cause of maternal health issue that perpetuates one renewed interest in the issue of death is of paramount importance.
of the greatest social injustices preventing unintended pregnancies separating rich and poor nations. has brought renewed focus on Steven W. Sinding
the role family planning and Director-General, Unsafe abortion is a cause and reproductive health services play in International Planned Parenthood consequence of poverty; it is also preventing unwanted pregnancies. intimately linked to gender

Member Association strives to reduce the number of unwanted distribution schemes for contraceptive services in rural areas Unsafe abortion, maternal mortality and
the Millennium Development Goals
The World Health Organization defines abortions as unsafe when they "Latin Americans are beginning
are performed by "persons lacking the necessary skills or in an environment to look at abortion as an issue
lacking the minimal medical standards or both". The impact of unsafe of maternal mortality, not
abortion casts a spotlight on the gaping social and public health just maternal morality."
inequalities between developed and developing nations, as well as within New York Times, 06 Jan 2006 those nations where abortion is illegal or severely restricted. There is onesimple truth: unsafe abortion disproportionately affects the poorestwomen in those countries where it occurs.
Unsafe abortion:
a cause and consequence of poverty
Poverty has multiple dimensions complications from unsafe abortion potential has an unequivocal which include a lack of economic account for approximately 70,000, impact on a woman's ability to play resources, an absence of human or 13 per cent, of all deaths. a full economic, social and political rights, poor health and the role within her community, and deprivation of choices. At the Achieving the Millennium is directly linked to poverty. For United Nations Millennium Summit, Development Goals, especially the young women and girls, unintended in October 2000, 191 countries goal of improved maternal health and unwanted pregnancy frequently agreed on the imperative of and reduced maternal mortality, will forces them to decide between reducing poverty and inequity require action across a broad front.
risking their lives and health to have worldwide. Improving maternal The causes of maternal mortality an unsafe abortion or leaving school health and reducing by three- and morbidity are numerous and to continue with the pregnancy.
quarters the number of maternal complex, but in countries where deaths were identified as one of women can be responsible for up "A poor woman in many parts
the Millennium Development Goals to 100 per cent of household of Africa is over 200 times more
key to addressing inequality.
income and for raising a family, likely to die as a result of
death and morbidity from unsafe pregnancy and childbirth than
Almost all maternal mortality abortion exacts a heavy economic a woman in the UK."
occurs in developing countries, and societal toll. representing one of the widest, Department of International and most unjust, health gaps Equal access to education for girls Development, UK.
between developed and is another key aim of the developing nations. Of the Millennium Development Goals.
500,000 annual maternal deaths, The failure to fulfil her educational Unsafe abortion:
the cost of gender inequality
Many women, married or They lack control over their own pregnancy and unsafe abortion, but unmarried, simply have no control bodies, just as they lack decision it is also a significant factor fuelling over their own sexual lives. They making power, mobility and control HIV infection rates amongst young cannot access, or are not permitted of resources within the household.
women in many countries. to access, safe family planning This social, political and economic services and as a consequence have inequity prevents many women Gender inequality, cultural norms, little choice over when or if they from accessing safe services or from religious practices and poverty are become pregnant. The prevailing demanding the services they desire.
all factors limiting opportunities for cultural and religious norms of women and girls to make choices many societies leave women, Young women, adolescents and about their own sexual and especially young women and girls, girls are particularly vulnerable to reproductive lives. This leaves girls facing death or injury from unsafe sexual coercion, abuse and and women without the choice to abortion, or social exclusion and exploitation. Almost 50 per cent say ‘no' to sex, especially if they are of sexual assaults worldwide are poor or living in marginalized against adolescent girls of 15 years communities. This has dire Many girls and women are of age or below. They are powerless consequences for many women, prevented from enjoying basic in relationships where older men especially the very poorest women.
sexual and reproductive rights due control their lives. This not only puts to their unequal status in society. them at greater risk of unwanted Millions of women suffer injury or illness from unsafe abortion
While the death of a mother, In countries where abortion is permitted only on narrow grounds, daughter or sister from unsafe thousands of women are hospitalized each year with serious complications abortion has a devastating impact from unsafe procedures.
on a family, equally devastating arethe debilitating injuries and illness or lifelong disability hundreds-of- thousands of women suffer as a Country hospitalizations consequence of unsafe abortion.
Accessed early, medical care can address the complications in many cases, but large numbers of women have no reliable access to primary Bangladesh, 1995 health care facilities. Not all women Phillipines, 1994 are able to get hospital treatmentfor medical complications following unsafe abortion; however, the data from 10 countries indicate the sheer scale of the problem and its subsequent impact on health Dominican Republic, 1990 care systems.
Health impact caused by
unsafe abortion
Alan Guttmacher Institute, Sharing Responsibility; Women, Society and Abortion Worldwide A WHO study from Nigeria in 2000showed that 75 per cent of women Pelvic abscess 3%
Over 80 per cent of the 809 case suffered injury or illness. The study Uterine perforation with
studies from all levels of Kenya's of 144 women who underwent health care system had unsafe abortion in Ilorin, Nigeria, Laceration of vaginal wall 3%
complications as a result of unsafe reported typical complications: Vesicovaginal fistula 1%
abortion. Of the seven deathsrecorded, six were due to second A more recent Ipas study from trimester complications; underlining Sepsis 27%
Kenya (The Magnitude of Abortion the need for safe and accessible Anaemia (haemorrhage) 13%
complications in Kenya, International abortion services as early as possible Journal of Obstetrics and during the pregnancy. The study Cervical tear 5%
Gynaecology) supports the Nigeria estimates that annually 20,893 Injury to gut 4%
data, declaring unsafe abortion as Kenyan women will be hospitalized Chemical vaginitis 4%
"one of the most neglected health from complications from unsafe Sepsis with anaemia 3%
care issues in Africa".
Worldwide unplanned pregnancy
and unsafe abortion
Unsafe abortion in Europe
There are approximately 211 million across the world women choose WHO estimates that there are
global pregnancies annually; 87 to end pregnancies for very similar between 500,000 – 800,000
million women become pregnant unsafe abortions in Europe each
unintentionally, with approximately year. Women are still dying in
46 million pregnancies ending in • They choose not to have any Eastern Europe from unsafe
induced abortion. A further 31 abortion, but the situation is
million pregnancies miscarry or • They are too young or have too improving. Between 6 and 23
result in stillbirths.
few economic resources to have per cent of maternal deaths in
Women in all parts of the world Eastern and Central Europe are
• They wish to complete their seek to end unwanted pregnancy as a result of unsafe abortion.
through abortion: of the 46 million women who choose to have an • They wish to postpone In order to improve women's abortion each year, 78 per cent are childbearing to space births access to safe legal abortion, IPPF from developing countries, 22 per • Their relationship with their European Network, in partnership cent from developed countries.
partner has ended or is unstable with other organizations, organized Annually 19 million abortions are • Childbearing would adversely a two-day workshop of staff and considered to be unsafe, over 96 affect their health volunteers from the Member per cent of which occur in • The pregnancy was a result of Associations of Albania, Armenia, developing countries. Bosnia and Herzegovina, Georgia,Kazakhstan, Poland, Tajikistan and A number of independent studies • Social or religious beliefs make it Uzbekistan. An additional meeting have shown that, while there may impossible for unmarried women was held with other European be country-to-country differences, to continue pregnancy Member Associations to assistthem in improving the quality ofabortion services provided.
A law banning abortion was
passed in Romania in 1966.
There was a dramatic rise in
maternal mortality from 80
deaths per 100,000 live births
in 1964 to 180 in 1988. After the
All abortions by
Unsafe abortions in
repeal of this law in 1989, the
maternal mortality ratio fell to
around 40 deaths per 100,000
Africa 11 per cent Africa 4.2 million live births in 1992. This fall was
America and the Caribbean almost entirely due to women
Europe 17 per cent Latin America and Asia 10.5 million being able to access safe
Caribbean 9 per cent abortion services and
consequently fewer deaths
Alan Guttmacher Institute, Sharing Responsibility; Women, Society and Abortion Worldwide caused by the complications of
unsafe abortion. During the
"In the face of growing conservatism in many parts of the world, as
period 1966-1988, some 20,000
well as competition for resources, the great challenge is to maintain
Romanian women are estimated
the focus of development efforts, as embodied in the Millennium
to have died as a result of
Development Goals, on the centrality of sexual and reproductive
health and rights for poverty reduction. This requires that IPPF step
up its advocacy efforts, in partnership with like-minded governments
and organizations, even as it expands its services in traditional
family planning and especially safe abortion."
Dr. Jacqueline Sharpe, President IPPF.
In compiling this report, IPPF has relied on statistical data from a numberof sources, most extensively from the Guttmacher Institute's landmarkpublication ‘Sharing Responsibility: Women, Society and AbortionWorldwide', 1999.
Unplanned births are common events
for women around the world
Increasingly women desire smaller families. With the exception of sub- The causes of unplanned and
Saharan Africa and a handful of other countries this largely means having two or three children. In much of the developed world a small family size • Gender inequality means women is the cultural norm. Yet many women throughout the world still have have less control over their more children than they would desire. • Lack of access to family planning • Lack of information on modern contraceptive methods and reliance on traditional methods • The failure of, or irregular use of, • Stigma surrounding single women and contraceptive use • Lack of a woman's control over the circumstances of sexual • Sexual violence, rape and incest • Cultural and religious norms mean women have less power to negotiate contraception Better contraceptive choices
To have full control over the spacing of children and to achieve desiredfamily size, women and men must use, correctly and consistently,reliable contraception for the majority of a woman's fertile years. Evidence suggests that globally the number of married and unmarried women regularly using modernmethods of contraception to avoid unplanned pregnancy is well belowthe numbers who wish to delay or better space their pregnancies.
The reasons for this are complex, ranging from ingrained social and cultural attitudes, economic circumstances and the inability of women to negotiate contraceptive use in relationships. Another reason is that in large parts of the world there is an unmet contraceptiveneed, and women and men simplycannot access the family planning services they want and need. Many % of births in last five years couples are forced to rely ontraditional methods which are not Preferred at later time effective in preventing pregnancy.
This inevitably leads to unplanned Alan Guttmacher Institute, Sharing Responsibility; Women, Society and Abortion Worldwide

Case studies:
unplanned pregnancies
In Nepal early marriage and They discovered that she had not Carmen, a 19-year-old woman,
multiple unplanned pregnancies returned to the clinic that morning came to a clinic of IPPF's Peruvian have lead many women to seek because she had been sitting an Member Association, INPPARES, secret and unsafe abortions.
exam. By now it was the weekend, depressed and emotionally upset.
Abortion was legalized under and although the clinic was She revealed during the conversation specific conditions in 2002, and the officially closed for the day, the that she had been raped six weeks implementation of the legislation branch manager was concerned earlier, but had not reported it or was approved in early 2004. This about further delays and opened sought medical care because she legal reform was contained within the clinic especially for the girl, who felt ashamed. In desperation, she the Pregnancy Protection legislation was accompanied by her guardian.
had attempted to induce an which addressed other rights for abortion using medication and was women. IPPF Member Association, A 36 year old pregnant woman
suffering from vaginal bleeding. the Family Planning Association of who had learned about the Nepal (FPAN), began providing services of the Family Planning Carmen's boyfriend and mother abortion services in 2004 in three Association of Nepal through were with her during the visit, and different clinics.
outreach workers, came to a clinic she was able to talk openly about in mid-2005. She and her what had happened and to discuss A 14-year old girl arrived at
husband, a labourer, were poor the options available to her. In FPAN's Valley clinic and requested and were already struggling to addition to information on post- an abortion. Initially she was bring up their seven young abortion care, she was offered reluctant to speak to the staff, children. She was clearly distressed counselling on testing for HIV and but she eventually revealed that that an eighth child would mean other sexually transmitted she had been involved in a sexual that none of her children could be infections. The woman decided to relationship with a distant provided for adequately.
have a manual vacuum aspiration, relative and had become which was completed without pregnant. A bright student, she Unfortunately, FPAN is unable to complications. When she returned was worried that a pregnancy offer free services for all clients, and for a follow-up visit, she was would affect her forthcoming the woman could not afford the counselled on different exams and would prevent her 750 rupee (approximately £6) fee.
contraceptive methods. She said from completing her education.
Realizing that she was in an that her boyfriend had left her due extremely vulnerable condition, to the stigma associated with rape It was the first time that such a and fearing the woman might and abortion, and that she no young person had requested these resort to an unsafe, ‘traditional' longer needed contraception.
services from the clinic, so staff did abortion method, FPAN staff not have a standard procedure to decided to raise the money for follow. A meeting was quickly the operation themselves.
called with service providers and services in theNouadhibou clinic senior staff to discuss the legal For many women, safe abortions of the Mauritanian implications and how best to help are very expensive and Member Association, the girl. In Nepal it is illegal to unaffordable, and going into debt these services are fundamental provide abortion services to anyone is not an option. This is one of the under the age of 16 unless she has many reasons women resort to the consent of her parents or unsafe abortion.
guardian. The staff decided thatthey would provide safe abortion The woman received a safe services the following day, so long abortion and post-abortion as the girl could return to the clinic counselling, including contraceptive the following morning with a counselling. The woman told staff guardian's consent letter.
that had she known about FPAN's family planning services sooner, she The next day, she did not come would have taken steps to have back to the clinic and staff became fewer children.
that women areeducated about worried. FPAN field staff made different methods discreet enquiries, and they met with the girl in confidence andprovided additional counselling.
All case studies in this report came from IPPF Member Associations

Buzensu walks forseveral hours toattend the marketday outreach servicesin Wondogonet,Ethiopia. TheSaturday clinic is heronly point of accessfor contraceptiveservices The global commitment to family planning
At the International Conference on world leaders are as far away as religious opposition, contribute Population and Development in ever from delivering on their directly to unintended and Cairo in 1994, the international commitment. Indeed, funding for unwanted pregnancies and to community pledged to make global family planning services has subsequent high levels of maternal universal access to family planning actually fallen during this period.
mortality and ill health from unsafe and sexual and reproductive health services a reality by 2015. Over a Non-existent or poor quality family decade later, and despite further planning services, whether from pledges to deliver universal access, inadequate funding or political and The Global Gag Rule
First introduced in 1984 and rights. Around the world this has "It has never been easy to fully
reintroduced by President George had a dramatic impact on the ability quantify the impact of the Gag
W. Bush in 2001, the Global Gag of IPPF Member Associations, and Rule. Its ramifications are
Rule puts non-governmental many other organizations, which insidious and have occurred over
organizations from outside the have rejected the Gag Rule, and many years. It is impossible to
United States in an untenable consequently lost much of their track how many deaths have
position, forcing them to choose funding, to provide full sexual and been associated with services
between carrying out their work reproductive health services. The safeguarding the health and rights policy has restricted the freedom of that could have been provided
of women or losing their funding speech and association of those in the absence of a Gag Rule,
from the US. The Gag Rule prohibits organisations who are bound by its how many advocates were
organizations in receipt of US funds regulations. However, anti-abortion silenced from speaking out about
from using their own money to advocacy is allowed, underscoring a devastating public health issue,
provide abortion information, the ideological nature of the Gag or how many organizations were
services and care, or even discussing prohibited from working with
abortion or criticizing unsafe their governments and other
abortion. It even prevents The Gag Rule fails in its stated organizations from working on intent to reduce the global Organisations to meet the
these issues at the request of their incidence of abortion. Rather, by serious health care needs of their
own governments.
dramatically impairing the deliveryof sexual and reproductive health own communities."
The Gag Rule severely restricts services, its actual impact has been Planned Parenthood Federation of freedom of speech; it interferes with to increase the number of America, Report on Global Gag the doctor-client relationship; and unintended pregnancies and the hinders balanced consideration of abortions that inevitably follow.
liberalizing abortion laws based onpublic health concerns and human Country profile: Kenya
The need to access
size and the government's launch high, with 24 per cent of couples of a national family planning unable to access the services they programme, Kenya saw a rapid desire, and family planning services IPPF is committed to a two- decline in its birth rate, on average have been reduced, largely due to pronged approach to reducing, and from eight children per woman the imposition of the Global Gag to slightly over four. Yet maternal Rule. Yet the abortion rate remains maternal mortality. The first is to mortality hardly declined and high, indicating that Kenyan provide those services that reduce abortion rates remained high women continue to turn to the need for abortion; where good (estimated at over 300,000 abortion to manage their fertility. contraceptive services are provided abortion rates decline. However, no Access to contraceptive services matter how effectively contraceptive As abortion is severely restricted reduces the number of unplanned services are provided and used, under Kenyan law, the only pregnancies and subsequently the unintended pregnancies will still exception being to save the life of number of abortions. Where there the mother, the vast majority of is an unmet need for family abortions are illegal and unsafe, planning and contraception, as the IPPF's second goal is to make accounting for some 30-50 per Kenyan experience demonstrates, abortion legal and safe everywhere. cent of national maternal mortality women resort to abortion to avoid The evidence is clear: only when rates. The impact on the resources childbearing. In countries where women have the right to access of Kenya's healthcare system is abortion is illegal or restricted, this safe abortion services do medical enormous, with as much as means women put their lives and complications from unsafe abortion 60 per cent of the resources of well-being at risk by resorting to and maternal mortality become Kenyatta National Hospital's unsafe abortion. Safe and legal maternity ward taken up by abortion services must exist This approach is dramatically victims of unsafe abortions.
alongside effective family planning highlighted in Kenya. Between and reproductive health services to 1980 and 2000, driven by demand Unmet need for family planning prevent deaths and tackle the from couples to limit their family throughout Kenya remains very health impact of unsafe abortion.
Kenya and the Global Gag Rule
IPPF's Member Association in Kenya, the Family Planning Association of Kenya (FPAK), provides a significant share of the country's contraceptive contraceptive need and
and reproductive health services. Faced with a choice between losing all contraceptive failure will
its funding and technical aid from the US Agency for International invariably be associated with
Development and stopping all its work on safe abortion, FPAK chose to high rates of unplanned and
forfeit the aid to be free to advocate for the health and well-being of unwanted pregnancies, forcing
Kenyan women. The resulting loss of funding saw the closure of three many women to resort to
FPAK clinics, the scaling back of services in its remaining clinics and theslashing of funding to outreach programmes. This has made it much unsafe termination of
harder for poor Kenyans to access family planning services and pregnancy with a consequent
information, and must inevitably lead to more unwanted pregnancies unacceptably high rate of
and unsafe abortions.
complications including
infertility, long term morbidity
The need to review abortion legislation
and death."
In early 2004, a number of Kenyan medical practitioners, accused of The Magnitude of Abortion performing abortions, were put on trial for murder. In response the complications in Kenya, RCOG Kenyan Reproductive Health Steering Committee was established, International Journal of Obstetrics comprising representatives from across Kenyan society, to defend the accused and to extend reproductive health and rights in Kenya. Through the Steering Committee's work, a draft motion to liberalizethe law on abortion will soon be tabled in the Kenyan parliament and a comprehensive national review of abortion is being undertaken. Themobilization of those who support improved access to safe abortionhas lead directly to the challenge to Kenya's abortion laws. Had thoseorganizations, including FPAK, signed the Gag Rule this challenge couldnot have happened, even at the behest of their own government.

IPPF/Asociación Civilde Planificación The VenezuelanMember Associationand their volunteersare key players in the campaign to decriminalizeabortion inVenezuela 29 Countries have liberalized
Abortion law reform efforts in Venezuela
their abortion laws despite
the imposition of the Global
Gag Rule in 1984
South America has long Asociación Civil de Planificación experienced the ravages of severe Familiar. In a country where the Albania - 1996
restrictions on abortion with some Catholic Church exerts a powerful Algeria - 1985
of the highest maternal mortality influence over society, the Australia - 2002 (two States)
rates from unsafe abortion in proposal for decriminalization is a Belgium - 1990
the world. In Venezuela, abortion first step in opening up a much Benin - 2003
is legal only to save the life of needed public and legislative Botswana - 1991
a woman, and there are no discussion on abortion.
Bulgaria - 1990
exceptions for rape, incest or Burkina Faso - 1996
to preserve a woman's health.
The Asociación Civil de Additionally, the law prescribes up Planificación Familiar helped draft Cambodia - 1997
to two year's imprisonment for a the proposals and presented the Canada - 1988
woman who undergoes an public health concerns of unsafe Chad - 2002
abortion and up to 30 months' abortion to the Congressional Czech Republic - 1986
imprisonment for the provider.
Commission on Women, Family Ethiopia - 2004
and Youth, which now supports France - 2001
On 1 December 2004, a proposal the proposals. The Commission Ghana - 1985
to decriminalize abortion was changed its position significantly Guinea - 2000
presented publicly before the once members heard the stories Greece - 1986
National Assembly. For health of women who needed access to Iran - 2005
professionals, weary of seeing safe abortion facilities, and saw Malaysia - 1989
women die from complications first hand the impact of maternal resulting from unsafe abortion, mortality and morbidity. They Mali - 2002
this was a momentous event.
recognized that criminalizing Mexico - 2000 (two States)
The bill represented the efforts of abortion was neither preventing it Mongolia - 1989
many women's organisations, from taking place nor reducing the Nepal - 2000
universities, obstetrics and demand for it, but only making Pakistan - 1990
gynaecological societies, the women suffer; they subsequently Romania - 1989
Ministry of Health and agreed that current legislation Slovakia - 1986
reproductive health providers, needed to be reformed.
South Africa - 1996
including the IPPF Member Spain - 1985
Association in Venezuela, Switzerland - 2002

Opposition to family planning undermines efforts to
reduce unwanted pregnancy and unsafe abortion
planning services Association clinic maternal mortality The sexual and reproductive "Accessible, effective family
Where access to
health and rights community planning services may avert up
faces increasingly hostile political to 35% of maternal deaths"
planning services and
opposition from the United States, Reducing Maternal Death:
information is available
the Vatican and other conservative Evidence and Action, A Strategy
abortion levels have fallen:
governments and religious leaders.
for DfID, September 2004.
This has ensured that universal The number of abortions in
access to reproductive health Armenia, Kazakhstan, Kyrgyz
A study of 15 West African
services remains a distant hope for Republic, and Uzbekistan could
countries found that those with
the majority of the world's poor.
be halved if women who do
the highest contraceptive
The direct result is that women not use contraceptives or use
and girls across the globe continue prevalence had the lowest
traditional methods switched
to bear the brunt of policies that maternal mortality rates, and
to modern contraceptives.
fail to address the nature and vice versa.
scale of maternal mortality and Bangladeshi women with
unsafe abortion.
good access to high quality
family planning services have
an abortion rate of 2.3 per
1000 compared with 6.8 for
women without access. (Duff
Gillespie, The Lancet, Vol. 363,
January 2004).
Creating the platform for change:
evidence-based interventions
The ideological debate surrounding liberalizing abortion laws and Colombia, which prohibits abortion abortion masks an unspoken truth: simultaneously increasing access to even to save a woman's life, when faced with an unwanted safe services is compelling.
averages one abortion per woman pregnancy many women will seek throughout her reproductive years.
an abortion regardless of its legality Proof that criminalizing abortion In Peru, this rises to an average of or safety. The deadly consequences does not reduce abortion rates, but two abortions per woman. For of this are all too evident; women's instead endangers women's lives, poor women, unable to afford safe lives are put at risk and all too can be seen across all global treatment, this means resorting to often they die or suffer lifelong regions. In Latin America abortion illegal unsafe abortion at the hands disability. The illegality and the is illegal or severely restricted in of unqualified people in unsanitary stigma attached to abortion make virtually every country, yet the evidence difficult to find. However, abortion rate is one of the highest when research is undertaken and in the world, far exceeding that of the facts are analyzed, the case for Western Europe or North America.
Country profile: Uganda
The controversy surrounding when support and political commitment findings led the delegation to make and how abortion should be legal for legal reform of abortion laws.
a declaration that stressed the in Uganda hides a vicious reality for importance of increasing access to women. Currently abortion is illegal The result of restricted access to safe, legal abortion, particularly for with the exception of saving a family planning services is that the poor, vulnerable and rural women.
woman's life, or to preserve her average Ugandan woman gives This declaration was publicly physical and mental health.
birth to seven children during her discussed with Ugandan Members However, additional administrative lifetime, two more than she would of Parliament, Ministry of Health barriers exist as an abortion has to prefer. Many women break the law officials and the media which be performed by a registered to end unwanted pregnancies in stimulated considerable public physician, and the consent of two unsafe and unhygienic conditions.
debate. This has lead the Head additional doctors is usually sought. The greatest impact of this is felt by of the Reproductive HealthUnder the Ugandan penal code, the poorest women in Ugandan Programme to acknowledge performing an illegal abortion is society, especially those living in publicly that legal abortion would punishable by up to seven years in rural areas who are driven to using reduce the maternal death rate.
prison for both the woman and the sharp instruments and herbs in a The Ministry of Health is planning doctor, yet this has done little to desperate attempt to end an to review the abortion law and reduce the level of unsafe illegal unwanted pregnancy. Upwards of is considering how the current seventy-five per cent will suffer abortion law can be better health complications, and unsafe interpreted so as to prevent further Uganda is one of the world's abortion now accounts for one unnecessary mortality and poorest countries, with nearly 40 third of all maternal deaths in morbidity from unsafe abortion per cent of people living below the poverty line. DfID funded researchreleased in 2005 has shown that Such strong factual evidence Using evidence to support the case one third of Ugandan women are cannot be ignored. There is already for reducing rates of unwanted denied contraception because they a groundswell of support for pregnancy through improved have no access to services. This change. In September 2005, IPPF access to safe abortion, IPPF's supports evidence from the Family and the Family Planning Association Member Association has appealed Planning Association of Uganda of Uganda facilitated a fact-finding to the Government for repeal of and builds a real and tangible mission by some Norwegian the current restrictive abortion laws argument to generate public Members of Parliament. The on public health grounds –something that could not havehappened had the Family PlanningAssociation of Uganda signed theGlobal Gag Rule. Worldwide abortion law:
A public health concern
• Prior to 1950 safe abortion was Grounds on which abortion is permitted around the world
illegal or severely restricted in virtually every country worldwide To save the woman's life • Growing concerns about the impact of unsafe abortion saw a Also to preserve physical and mental health rapid increase in the number of Also in cases of rape or incest countries liberalizing or legalizing abortion, primarily in the Also in cases of fetal impairment developed world but also in other Also economic or social reasons • This trend slowed after 1984 when the Global Gag Rule was Population concerned (millions) Number of countries • Between 1985 and 1997 another The World Health Report 2005, WHO 19 countries eased abortion laws • More recently, another 11 countries have liberalized their Access to safe and legal abortion services
Ensuring adequate information This is equally true of affordability.
• At the same time five countries about abortion and access to safe High costs involved in acquiring a have tightened their laws and affordable abortion services safe abortion affect poor women • 25 per cent of the world's are as important as legalizing the most and can lead to women population continue to live in abortion; unless these things are delaying an abortion until a later, countries where abortion is illegal concurrent, unsafe abortion will more dangerous stage of pregnancy. or severely restricted continue to devastate the lives ofmillions of women worldwide. In India, despite 30 years of legal • In other countries, access to provision of abortion services, there services and information is being In countries where abortion is continues to be a ratio of severely restricted while abortion allowed, legal barriers can approximately 6:1 of illegal to legal remains legal under certain significantly delay access to safe abortions, contributing to over 15 services which can have negative per cent of the maternal death rate.
• The interpretation and consequences for a woman's well- This is largely due to lack of enforcement of national laws, being. Mandatory waiting periods, awareness of the legal status of and the attitude of the medical the need for spousal or guardian abortion, a lack of access to safe, community towards abortion, consent and the need to travel hygienic abortion services and a critically affect access to services long distances to an authorized shortage of skilled medical • Studies have proven that provider all act as impediments to personnel, especially in rural areas.
legalizing or liberalizing abortion accessing safe abortion. laws does not lead to an increasein the over all abortion rate Country profile: Mongolia
Abortion is legal in Mongolia, Long queues and bureaucratic As a first step in this process, although government policy procedures force many women to MFWA undertook a survey of over does not always translate into go to private uncertified clinics 1,700 people to find out more concrete services to decrease where abortions can be procured about public opinion and unsafe abortion. The strict rules quickly, but there are higher fees experiences around abortion. for service provision state that and they operate illegally. Access, A cross-section of the public was abortions must be carried out at particularly in rural areas, remains interviewed, which revealed that a medical facility certified by poor. Because of this situation, most of the respondents had high the government. While this may IPPF's Member Association the awareness of abortion availability ensure high quality services, the Mongolian Family Welfare and eligibility. Residents in rural reality for women is that few legal Association (MFWA) is advocating areas, where there are no private options are available apart from for an alternative system where clinics or public hospitals within the services at government simpler clinics could also provide easy reach, supported plans to hospitals. This situation serves to safe legal abortion, with measures make abortion services more restrict access to services.
in place to ensure that health and accessible, indicating that there safety standards remain high. was a significant demand foraccess to safe abortion services.
Country profile: Ethiopia
Gete (not her real name), a 22 When she found out she was year old Ethiopian woman, came pregnant Gete decided she into a Family Guidance Association wanted an abortion and,clinic in Addis Ababa because she overcoming her fears, she went to had been raped. She originally the police. They sent her to the came from Gondor in the north clinic to get confirmation, but but moved to Addis to find work, because she was already four living with her aunt and uncle months pregnant clinic staff were unable to confirm whether shehad been raped and were limited Gete was raped by a friend of her to providing counselling and cousin. At the time abortion was confirming pregnancy for the illegal in Ethiopia other than in cases of rape and incest, and toaccess abortion services a woman "If the woman does not receive needed to obtain a police report the correct documentation from confirming rape (this law has the police, the clinic will be unable recently been liberalised). The to refer her for a safe abortion. In stigma surrounding rape and cases like this it is common for abortion is great and she was women to visit illegal reluctant to go to the police, thinking they would not believe Sister Mekele, head nurse of the identity revealed in her. When she told her uncle she Addis Ababa model clinic.
had been raped he threw her out.
Medical abortion: Saving lives in
resource poor settings
Medical abortion, a combination of Medical abortion up to nine weeks' Sarawati, a 37 year old health
medications, is a safe and highly gestation requires two clinical visits care worker from India said
effective method for ending an to administer two separate drugs, "I wish this method [medical
unwanted pregnancy, and is but can also be administered at abortion] was available when I
increasingly the preferred method home which is increasingly the case was young and had an
in many developed and some for its second administration.
unwanted pregnancy. I went to
developing countries. At present it Following administration of the a Dai [traditional healer]
is largely unavailable to women prostaglandin on the second visit, because I did not want to have
living in the latter. Provided by 90 per cent of women will abort surgery done by the male
trained personnel, complications within 4-6 hours.The procedure has doctor; I had pain and fever for
a 98 per cent efficacy rate. Beyond many days. I never could get
the nine week period there is a pregnant after that, and my
Using the antiprogestogen, requirement for additional husband left me."
mifepristone, in conjunction with a treatment, although never as synthetic prostaglandin analogue, invasive as surgical abortion, and it Medical abortion has been
the effects of medical abortion are has a 97 per cent efficacy rate.
used for over a decade in many
similar to those of spontaneous European countries. In some
abortion. In countries where One of the major benefits of surgical abortion presents severe medical abortion in developing countries it now accounts for
medical or financial difficulties for countries is that, for the vast over 50 per cent of abortions
primary healthcare systems, majority of women, the procedure undertaken (Sweden 51 per
medical abortion has proved to be can be carried out on an outpatient cent; France 56 per cent;
effective and user friendly, and basis, requiring far fewer medical Scotland 61 per cent).
offers real hope of making safe abortion much more accessible tothose women who need it most.
HIV-positive women and their right to choose
positive and visits run by the Family Ethiopia to talk to Women of childbearing age living access to comprehensive decisions. However, what with HIV are as likely to have an prevention of mother-to-child emerges from current research unplanned pregnancy as those transmission programs, HIV is the lack of respect and value who are HIV negative, and are positive women who give birth placed on HIV positive women's equally faced with the question of to HIV positive children are often whether to have a child or not.
However, in the case of the HIV It is clear that provision of positive woman, the issue is more The right to have a family and services needs to be based on complex, for personal, familial, decide whether and when to have the respect for the woman's social, cultural, religious and children is a fundamental part of a sexual and reproductive rights medical reasons.
woman's sexual and reproductive and decisions, including, if freedom. Yet, women living with needed, the right to safe and Women living with HIV are often HIV are frequently denied this legal abortion. Making available stigmatized for being HIV positive right because society and service safe abortion services is and, if pregnant, for irresponsibly providers do not believe that HIV extremely important for HIV being sexually active and positive women should have positive women as unsafe becoming pregnant while HIV children, or should even be abortions become significantly positive. Sometimes they are sexually active.
less safe due to the greater risks under pressure by family or health HIV positive women face of workers to have their pregnancy This is a tragic picture, which suffering complications such as terminated, while in other cases paints HIV positive women as both sepsis and haemorrhage.
they are pressured by partners and culprits and victims, and implies a society to have children. Women degree of coercion in the decision- No matter what their status living with HIV can also be making process. To date, few women should have the right to demonized for seeking or having studies have explored how HIV decide for themselves whether an abortion. In the absence of positive women make childbearing or not to bear a child.
Although abortion "That's how so many women confront
in Nepal has beendecriminalised the problem: ALONE."
and many womenimprisoned forillegal abortion Dr. Gladys Bazan – Gynaecologist, IPPF Member Association in Peru. have beenreleased, they arestill aware of thepotential stigmasurroundingabortion Country profile: Brazil
Every week at the Hospital das In the United States, where in Brazil. In 2004, some 244,000 Clinicas in Sao Paulo, Brazil's abortion was legalized in 1973, women were treated for largest public hospital, women are about 25 per cent of all complications from clandestine rushed to the emergency room pregnancies end in abortion. In abortions in public hospitals, with severe vaginal bleeding. the Netherlands, a country with costing the government 35 million some of the world's most liberal reals (£9 million). Most are in their teens or early abortion laws, the ratio is closer 20s and live in the dirt-poor slums Brazil's abortion laws also that encircle South America's highlight its gaping social biggest city. Some say they have Despite its prevalence, abortion inequalities. Well-to-do women no idea what caused the bleeding.
largely remains a taboo subject in resort to clandestine but safe Others tell elaborate stories of Brazil, the world's biggest Roman clinics to end their pregnancies, menstruation gone awry. Catholic country. But that is now paying as much as 1,500 reals changing as civic groups and some (£400) - five times the monthly But hardly any own up to the medical professionals prompt a minimum wage - for an abortion.
truth; scared of being turned in to public debate on abortion by the authorities in a country where championing a woman's right to Most poor women, by contrast, abortion is illegal, they are reluctant end an unwanted pregnancy. They turn to an ulcer drug called to admit they induced miscarriage want to prevent women from misoprostol, better known by the by inserting a black-market ulcer dying from clandestine abortions. brand name Cytotec. When medication into their vaginas.
inserted into the vagina Cytotec Currently, abortion is only allowed causes the uterus to contract, Although abortion is outlawed in in cases of rape or when the expelling the embryo or fetus.
Brazil except in rare circumstances, mother's life is in danger. But even the country has one of the highest then, getting a judge to authorize Reuters news agency report, abortion rates in the developing the procedure can be difficult, and world. The Health Ministry some doctors refuse to perform estimates that 31 percent of all abortions on religious grounds.
pregnancies end in abortion. Thatworks out to about 1.4 million Botched abortions are the fourth- abortions a year, mostly clandestine. leading cause of maternal deaths A future free from death and denial?
IPPF advocates for:
However, even with the most • Document the impact of efficient use of contraception unsafe abortion on women, "A universal recognition of
a woman's right to choose
unwanted pregnancies will still families and society and have access to safe
• Educate the public about the abortion, and a reduction in
consequences, the costs and The most important message from the risk of unsafe abortion."
the social injustice of unsafe this report for governments to IPPF Strategic Framework understand is that by criminalizing abortion the issue does not go 7.Tackle the stigma and
When abortion is legal and services away; women will continue to seek discrimination attached to
are both accessible and safe, the abortions for all the reasons outlined abortion and promote the
chance of a woman dying or being in this document, and women will open and frank discussion
physically harmed from either continue to die. We therefore need of abortion and its impact
surgical or medical abortion is to make sure that if a woman negligible. Indeed, abortion is one chooses to have an abortion, it is of the safest medical procedures. It both safe and legal.
The commitment of the is a public health tragedy then that Department for International almost 200 women around the This report has highlighted that we Development means that the world continue to die each and need to create the political will to: United Kingdom continues to every day due to complications promote a global approach to from unsafe abortion, virtually all of 1.Reduce unwanted
legalizing abortion based on them living in the developing world.
public health evidence. IPPF • Build upon past gains in sexual strongly supports this approach Women who are already facing a and reproductive health and will continue to work with future of limited opportunities and the Government of the United • Increase access to family social inequalities, who find Kingdom, as well as other themselves with an undesired donors, to spearhead this • Focus on the needs of poor pregnancy, must also encounter the often deadly risk of an abortion and rural women and men performed by someone without • Promote women's status Without the hard work of so many any medical training in unsanitary of our Member Associations who conditions, or by attempting to end have refused funding from the 2.Make safe and legal
an unwanted pregnancy themselves United States due to their belief in abortion available to every
with traditional methods.
safe, legal abortion, and who woman who wants it
continue to confront policy makers This report has sought to highlight 3.Address gender inequality
around the world, the future for some of the key issues related to • Create the circumstances in women in many countries would abortion in countries where it is which women are socially, remain unchanged. either illegal or severely restricted.
politically and economically Our hope is that one day women There is a gradual shift in the will no longer have to put their 4.Ensure that post abortion
abortion paradigm and a lives and health at risk from unsafe care services to women
movement towards liberalizing abortion; for this to be a reality who have incomplete
abortion laws. This report should abortion must be both legal and abortions or medical
help to keep up this momentum.
safe everywhere. It is IPPF's belief complications following an
By providing real evidence that a woman's right to choose abortion are included in
demonstrating the public health whether to have an abortion both public and private
impact of unsafe abortion, should never be compromised by particularly its links to social unwarranted intrusion from the inequality and poverty, we can law, or the very real risk of death 5.Eradicate unsafe abortion
hope to persuade governments to due to the lack of minimal medical • Increase access to safe and make abortion both legal and safe.
standards and skills.
We must continue to make the • Reduce legal and social arguments for a woman's right to It has been shown that by making barriers to safe abortion choose whether to have an family planning and reproductive abortion and to ensure that, if she health services available, the rate 6.Hold governments in both
does, she is not putting her life or of unintended pregnancy drops developed and developing
health in jeopardy. Only then can significantly, thus decreasing the countries accountable for
we look towards a brighter future need for abortion. where women no longer face therisk of death and denial.
Who we are
The International Planned Parenthood Federation(IPPF) is the strongest global voice safeguarding sexualand reproductive health and rights for peopleeverywhere. Today, as these important choices andfreedoms are seriously threatened, we are needednow more than ever. What we do
IPPF is both a provider and an advocate of sexual andreproductive health and rights. Our voluntary, non-governmental organization has a worldwide networkof 151 Member Associations in 183 countries.
Our vision
We see a world where women and men everywhere
have control over their own bodies, and therefore
their destinies. A world where they are free to choose
parenthood or not; free to decide how many children
they'll have and when; free to pursue healthy sexual
lives without fear of unwanted pregnancies and
sexually transmitted infections, including HIV.
We will not retreat from doing everything we can tosafeguard these important choices and rights forcurrent and future generations. Access Denied. (2005) The Impact Global Health Council. (2002) Vekemans, M and De Silva U.
of the Global Gag Rule in Kenya.
Promises to Keep: The Toll of (2005) HIV Positive Women and Unintended Pregnancies on Their Right to Choose. Entre Nous, Women's Lives in the Developing Access Denied. (2005) The Impact World. Global Health Council, of the Global Gag Rule in Nepal.
United Nations Population Fund.
Washington DC, USA.
(2005) The State of World International Centre for Research Population 2005. United Nations Alan Guttmacher Institute. (1999) on Women. (2005) Toward Population Fund, New York, USA.
Sharing Responsibility: Women Achieving Gender Equality and Society and Abortion Worldwide.
World Health Organization. (2003) Empowering Women. International Alan Guttmacher Institute, Safe Abortion: Technical and Policy Centre for Research on Women, Washington DC, USA.
Guidance for Health Systems.
Washington DC, USA.
World Health Organization, Bradford, Carol and Holmes, Sue.
Ipas, (1995) Ten Ways to Effectively (2005) Joint Output to Purpose Address Unsafe Abortion, Ipas, Review of DFID Funded Projects on World Health Organization. (2004) Chapel Hill, USA.
Access to Safe Abortion.
Unsafe Abortion: Global and Department for International Ipas. (2003) 5 Portraits, Many Lives: Regional Estimates of Incidence of Development, London UK.
How Unsafe Abortion Affects Unsafe Abortion and Associated Women Everywhere. Ipas, Chapel Mortality, 4th Ed. World Health Centre for Reproductive Rights.
Organization, Geneva, Switzerland.
(2004) Making Abortion Safe, Legaland Accessible: A Toolkit for Ipas. (2005) Global Abortion World Health Organization. (2005) Action. Centre for Reproductive News Update.
World Health Report 2005: Make Rights, New York, USA.
Every Mother and Child Count.
Nerquaaye-Tetteh, Joana. (no date) World Health Organization, Department for International Access to Reproductive Health Geneva, Switzerland Development. (2004) Reducing Services: Political Reality in Africa.
Maternal Deaths: Evidence and Planned Parenthood Association of Deliver. 2003. "No Product? No Action. Department for International Ghana, Ghana.
Program! Reproductive Health Development, London UK. Commodity Security for Improved Planned Parenthood Federation of Maternal and Child Health." Paper Gillespie, Duff. (2004) Making America. (2003) The Bush presented at the Fourth Ordinary Abortion Rare and Safe. The Administration, The Global Gag Meeting of the West African Health Lancet, 363:74.
Rule, and HIV/AIDS Funding.
Organization, Banjul, Gambia, Planned Parenthood Federation of America, Washington DC, USA.
International Planned Parenthood Federation
4 Newhams Row, London, SE1 3UZ, United Kingdom
Tel +44 20 7939 8200Fax +44 20 7939 8300 Email [email protected] www.ippf.org Cover photo: IPPF/Jenny Matthews Published in January 2006, London, United Kingdom 2006 International Planned Parenthood Federation

Source: http://www.ncsw.gov.pk/resource/previewlibrary/34