International Journal of Gynecology and Obstetrics 110 (2010) S13–S16

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International Journal of Gynecology and Obstetrics

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o

PRECONGRESS WORKSHOP

Critical gaps in universal access to reproductive health: Contraception and

prevention of unsafe abortion
Kelly R. Culwell a,⁎, Marcel Vekemans a, Upeka de Silva a, Manuelle Hurwitz a, Barbara B. Crane b
a
International Planned Parenthood Federation, Central Office, London, UK
b
Ipas, Chapel Hill, NC, USA

a r t i c l e i n f o a b s t r a c t

Keywords: Unsafe abortion accounts for a significant proportion of maternal deaths, yet it is often forgotten in
Abortion discussions around reducing maternal mortality. Prevention of unsafe abortion starts with prevention of
Contraception unwanted pregnancies, most effectively through contraception. When unwanted pregnancies occur,
Human rights provision of safe, legal abortion services can further prevent unsafe abortions. If complications arise from
Maternal mortality unsafe abortion, emergency treatment must be available. Recommendations made on this issue during the
Prevention
Precongress Workshop held prior to the 2009 FIGO World Congress in Cape Town, South Africa, were part of
a report that was adopted by the FIGO General Assembly. These recommendations address prevention of
unsafe abortion and its consequences and support access to safe abortion care to the full extent allowed by
national laws, along with 6 strategies for implementation, including integration of family planning into other
reproductive health services, adequate training for providers, task-sharing with mid-level providers, and
using evidence to discuss this issue with key stakeholders.
© 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction Women's Health. The Precongress Workshop brought together over

Unsafe abortion accounts for 13% of maternal mortality [1] and
results annually in nearly 70 000 deaths worldwide; 99% of these
occur in low-resource countries (35 600 in Sub-Saharan Africa;
28 400 in Asia; and about 2000 in Latin America, the Caribbean,
and Oceania combined) with only a few in high-resource regions
of the world (under 60 in Europe and North America combined) [1].
Besides mortality, unsafe abortion can be responsible for temporary
or permanent disability, including secondary infertility, in millions of
women.
As we approach 2015, it has been recognized that Millennium
Development Goal (MDG) number 5 (reducing maternal mortality
and universal access to reproductive health) has seen the least
progress of all of the MDGs [2]. Unfortunately, global initiatives
focusing on reducing maternal mortality largely ignore unsafe
abortion as a significant cause of maternal mortality and morbidity.
Unsafe abortion, along with HIV/sexual and reproductive health
linkages and adolescent sexual health, was selected as one of the
“critical gaps in universal access to reproductive health” to be
addressed during the Precongress Workshop held prior to the XIX
FIGO World Congress of Gynecology and Obstetrics in October 2009 in
Cape Town, South Africa, sponsored by the WHO/FIGO Alliance on
⁎ Corresponding author. International Planned Parenthood Federation, 4 Newhams
Row, London SE1 3UZ, United Kingdom. Tel.: +44 20 7939 8273; fax: +44 20 7939
8300.
E-mail address: kculwell@ippf.org (K.R. Culwell).
100 of the world's experts in women's health, approximately 40 of
whom chose to address the topic of unsafe abortion. The discussion on
unsafe abortion focused on 3 areas: preventing unwanted pregnan-
cies; prevention of unsafe abortion; and managing complications of
unsafe abortion to prevent morbidity and mortality.
2. Preventing unwanted pregnancies
As nearly all unsafe abortions are a result of unwanted pregnancies,
prevention of unwanted pregnancy is a logical best option for reducing
the number of unsafe abortions.
2.1. Promoting the use of contraception
The right to plan one's family and space one's children is specified
in Article 16.1 of the United Nations Convention on the Elimination of
all Forms of Discrimination Against Women (CEDAW) and was re-
emphasized in the Programme of Action from the International
Conference on Population and Development (Cairo, Egypt, 1994)
and the Platform for Action from the Fourth World Conference
on Women (Beijing, China, 1995). However, it is currently estimated
that 215 million women globally who wish to limit or space their
childbearing are not using a modern contraceptive method [3]. This
unmet need is greatest among the most vulnerable populations
with disproportionately high levels among poor, adolescent, and rural
women [3].

0020-7292/$ – see front matter © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijgo.2010.04.003
S14 K.R. Culwell et al. / International Journal of Gynecology and Obstetrics 110 (2010) S13–S16
The reasons for unmet need are both supply and demand driven.
Governments in many countries have failed to make funding for
reproductive health a priority in national budgets. Logistics problems
along with funding shortages create a lack of commodities in the
areas where they are most needed. The Guttmacher Institute and the
United Nations Population Fund (UNFPA) estimate that US $6.7 billion
annually is needed to meet current and unmet need for contraceptives
globally, a figure more than double that of current global investment
in family planning [3].
Healthcare providers themselves often impose unnecessary bar-
riers to provision of contraceptive services [4], including denial of a
contraceptive method on the basis of age, parity, marital status, or lack
of parental or spousal authorization, which can make it more difficult
for a woman to obtain and continue with a contraceptive. Moreover,
a limited choice of contraceptive methods and poor contraceptive
counseling can result in women being given contraceptive methods
that are difficult for them to continue. Ideally, internationally
accepted evidence-based protocols such as the WHO Medical
Eligibility Criteria [5] and Selected Practice Recommendations [6]
should be used to create evidence-based practice guidelines at the
country level and assist healthcare providers and program managers
in appropriate delivery of family planning methods.
Reducing the unmet need for contraceptives and unwanted
pregnancies is difficult without attention to comprehensive sexual
and reproductive health and rights. When women lack autonomy to
make decisions for themselves and their families, their access to
uninterrupted family planning services is compromised. Provision
of correct information is also crucial to combat the myths and
misconceptions held by women, their families, and communities
about contraceptive methods. Cultural and religious barriers, in-
cluding disempowerment of women, particularly the poor and those
living in rural areas, leads to lack of awareness of the availability of
contraceptive methods and inequitable access to services. The taboo
surrounding pre-marital sexual activity among young people often
leads to discriminatory laws or attitudes among healthcare providers
and clinic staff, which deters young people from being able to access
contraceptive services as well as comprehensive sexual and repro-
ductive health care.
2.2. Promoting general and sexuality education
Education is an important factor in the prevention of unwanted
pregnancy and unsafe abortion. Comprehensive sexuality education
encourages, where appropriate, a delay in starting sexual activity and
results in a reduction in the number of sexual partners and increased
condom or contraceptive use [7]. In contrast, there is no evidence
that abstinence-only education has any effect on reducing abortion
rates. Young people pledging abstinence until marriage will have sex
as soon as non-pledgers, but are less likely to protect themselves from
unintended pregnancy or sexually transmitted infections [8,9].
2.3. Eliminating gender-based violence
It is a tragic reality that many unsafe abortions are a result of
unwanted pregnancies after forced intercourse or violence, especially
for women who are young or in other vulnerable circumstances.
Women and girls in conflict situations suffer especially when rape is
used as a weapon of war. In a multi-country study conducted by WHO,
up to 30% of women in some regions reported that their first
experience of sexual intercourse was forced or coerced [10]. In
addition, the study found that the younger the girl was at the time of
sexual initiation, the more likely she was to report her first sexual
intercourse was a result of force or coercion [10]. This is particularly
significant to the issue of unsafe abortion, since it is estimated that
40% of unsafe abortions in low-resource countries were in women
under the age of 25. That number is nearly 60% in Africa [11].
3. Prevention of unsafe abortion: Replacing unsafe abortion by
legal safe abortion
According to the FIGO Committee for the Study of Ethical Aspects
of Human Reproduction and Women's Health, “Providing the process
of properly informed consent has been carried out, a woman's right to
autonomy, combined with the need to prevent unsafe abortion,
justifies the provision of safe abortion” [12].
Only 40% of the world population can access abortion without
restriction as to reason, within gestational limits [13]. Everywhere
else laws restrict access to safe abortion to a lesser or greater degree
[14]. There has been a trend in recent years toward reduced
restrictions within abortion laws globally. Of the 21 countries that
have changed their abortion laws since 1997, 19 of those reduced
restrictions. On the other hand, a few countries have increased their
restrictions, including El Salvador and Nicaragua—both eliminating all
legal indications for abortion, even when necessary to save a woman's
life [15]. While most countries allow safe abortion for conditions
endangering women's lives and health, the definition of health used
by the World Health Organization, “a state of complete physical,
mental and social well-being and not merely the absence of disease
or infirmity” [16], is rarely applied when interpreting such laws. It
is well understood that legal restrictions do not lower the incidence
of abortion; thus the abortion rate of 29 per 1000 women of repro-
ductive age in Africa, where abortion is mostly illegal, is similar to
that of 28 per 1000 women in Europe, where abortion is generally
permitted on broad grounds [17]. The difference is the high death toll
in Africa, where the abortions are predominantly unsafe.
The arguments for the provision of safe, legal abortion services
include those from a public health, human rights, social justice,
and even economic point of view. Even if contraceptives are widely
available and used, contraceptive methods are not perfect, nor are
users. Therefore, there will always be need for safe abortion services
when unwanted pregnancies occur. Abortion, when provided in a
safe environment by properly trained providers, is one of the safest
medical procedures [18]. Safe, legal abortion is an extremely effective
way of eliminating unsafe abortion and the deaths and long-term
consequences resulting from it [18]. Preventing these deaths could
make a significant impact in countries’ efforts to meet the MDG
5 target of a 75% reduction in the maternal mortality ratio by 2015.
Failing to provide access to safe abortion services or prosecuting
women for seeking abortion services is increasingly recognized as a
violation of a woman's right to life, right to health, right to be free
from torture and cruel inhuman degrading treatment and punish-
ment, and the right to non-discrimination [19]. In addition, the UN
Committee on Torture has held that forcing a woman to carry a
pregnancy to term that was a result of sexual violence entails
continued violation of her human rights [20]. However, many
countries do not allow legal abortion in the case of rape or incest,
and for those that do have legal exceptions for these reasons, access to
services for these indications is often limited or non-existent. Not only
does unsafe abortion carry a heavy human cost, but it also places
a burden on health systems that are already financially stretched.
The cost to the government health systems of treating complications
from unsafe abortion is several times that of contraceptive and safe
abortion services. It is estimated that health systems in developing
countries expend US $460–550 million per year (in 2006 dollars) to
treat severe consequences of unsafe abortion [15].
As noted above, increasing access to comprehensive abortion care
will reduce the practice of unsafe abortion and its consequences.
Comprehensive abortion care includes pre- and post-abortion
counseling, surgical and (where possible) medical drug-induced
techniques, and post-abortion care—both emergency services and
post-abortion contraception [21]. Post-abortion contraceptive
counseling and services, including availability of highly effective
long-acting contraceptives (intrauterine devices and implants) and
 K.R. Culwell et al. / International Journal of Gynecology and Obstetrics 110 (2010) S13–S16
sterilization, where appropriate, are essential components of post-
abortion care. These services should necessarily be both youth-
friendly and accessible to hard-to-reach segments of the population.
4. Managing complications of unsafe abortion to prevent
morbidity and mortality: Provision of quality post-abortion care
The stigma associated with abortion in many countries combined
with the restrictive legal environment and criminalization of the
woman lead to a lack of compassionate, appropriate care of the
consequences of unsafe abortion. A recent study from Gabon looked at
the delay in care from the time of presentation to the healthcare
facility to initiation of care among women who died from various
maternity-related causes [22]. For women who died from post-
partum hemorrhage or eclampsia, the delay in treatment was just
over 1 hour. However, the delay in initiating care for women who died
from unsafe abortion complications was nearly 24 hours from the
time of presentation to the health facility. Unfortunately, this is the
experience of far too many women in low-resource countries who
suffer complications from unsafe abortion. Adolescents, unmarried
women, or women with HIV may face double or triple stigmatization
of being pregnant outside of marriage or with HIV and then again if
they choose to end the pregnancy. When these women—or women
who are too poor to access care—experience complications of unsafe
abortion, they are far less likely to seek or receive treatment for
those complications. It is estimated that of the over 7 million women
who have complications of unsafe abortion, nearly 40% do not obtain
adequate care [15].
The harmful effects of unsafe abortion can be alleviated through
the provision of high-quality and timely post-abortion care. This care
includes basic treatments that are common in postpartum care,
including uterine evacuation (via vacuum aspiration or misoprostol),
antibiotics, analgesics, blood transfusion, and uterotonics such as
oxytocin. More severe complications will require secondary or tertiary
settings where surgical theatres are available, but most of the early
or minor complications can be treated in the primary care facility by
a trained, mid-level provider. These services simply need to be
available, of high quality, and women need to be aware of them and
able to access them with minimal delay. As noted above, however,
simply having the services in place will not ensure that all
complications of unsafe abortion are treated in a timely manner,
unless women feel safe in accessing the services and confident that
they will receive non-judgmental care.
5. Recommendations
The following recommendations for obstetrician-gynecologists
and FIGO member societies were presented to the FIGO General
Assembly as part of a full report on the proceedings from the Pre-
Congress Workshop on “Critical Gaps in Universal Access to Repro-
ductive Health.”
1. Ensure access to counseling and services for all effective
methods of contraception, including emergency contraception,
for all women, with special attention to the needs of those who are
young, those at risk of HIV, poor, rural, or in other vulnerable
groups.
2. Ensure that women with complications of unsafe abortion
receive the same quality of care as all other women, non-
judgmental, with minimum delay, and with attention to their other
sexual and reproductive health needs. Post-abortion care is part of
emergency obstetric care and should be available in all settings.
3. Ensure access to safe abortion care to the full extent allowed by
national laws in accordance with FIGO and WHO guidelines on
safe abortion, including clear regulations that protect obstetricians
S15
and gynecologists, other healthcare providers, and the women they
serve.
4. Strategies to implement these recommendations include:
a. Promote integration of family planning with postpartum,
abortion, and post-abortion care, in accordance with WHO
guidelines and the joint statement on “Family Planning: a Key
Component of Post-abortion Care” by FIGO, the International
Confederation of Midwives, the International Council of Nurses,
and the United States Agency for International Development.
b. Ensure that obstetricians and gynecologists receive adequate
pre-service, in-service, and on-the-job training on evidence-
based practices and technologies for contraception, abortion
care, and counseling, as well as on legal, social, and psycholog-
ical aspects of women's sexual and reproductive health.
c. Support task-sharing through the authorization, training, and
supervision of general practitioners, midwives, nurses, and
other mid-level providers to provide contraceptive and safe
abortion and post-abortion care.
d. Ensure that all obstetrician/gynecologists and other healthcare
providers receive adequate training and sensitization in human
rights principles, including sexual and reproductive rights.
e. Provide accurate evidenced-based information and accepted
ethical principles as a basis for informed dialogue with other
key stakeholders, including policy makers, the media, other
professional groups, and the public.
f. Strengthen capacities of FIGO member societies to provide
leadership in collaboration with other stakeholders in helping
women to prevent and manage unwanted pregnancies, includ-
ing access to safe and legal abortion as allowed by law.
Conflict of interest
The authors declare no conflict of interest.
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