Missed opportunities in women's health: post-abortion care
Authors: Marleen Temmerman
Journal: The Lancet Global Health (2018)

Around the world, 56 million induced abortions took place annually in 2010–14, which was about 25% of all pregnancies. Abortion rates vary widely across regions, do not differ significantly by income level or legal status of abortion,1Starrs A Ezeh A Barker G et al.Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission.Lancet. 2018; 391: 2642-2692Summary Full Text Full Text PDF PubMed Scopus (319) Google Scholar and depend on many factors, one of the key ones being a lack of access to modern contraceptives.1Starrs A Ezeh A Barker G et al.Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission.Lancet. 2018; 391: 2642-2692Summary Full Text Full Text PDF PubMed Scopus (319) Google Scholar Safe abortion, however, depends on the legal climate, and countries with restrictive abortion laws are far more likely to have illegal and unsafe abortions. Abortion-related complications are an important and preventable cause of maternal mortality, accounting for 8–9% of maternal deaths worldwide,2Say L Chou D Gemmill A et al.Global causes of maternal death: a WHO systematic analysis.Lancet Glob Health. 2014; 2: e323-e333Summary Full Text Full Text PDF PubMed Scopus (2807) Google Scholar with 42 to 63 women dying out of every 100 000 abortions. Globally, the rate of abortion-related deaths dropped by about 42% between 1990–94 and 2010–14, from 108 per 100 000 women to 63 per 100 000. The rate of such deaths is highest in Africa, at 141 per 100 000 abortions.1Starrs A Ezeh A Barker G et al.Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission.Lancet. 2018; 391: 2642-2692Summary Full Text Full Text PDF PubMed Scopus (319) Google Scholar, 2Say L Chou D Gemmill A et al.Global causes of maternal death: a WHO systematic analysis.Lancet Glob Health. 2014; 2: e323-e333Summary Full Text Full Text PDF PubMed Scopus (2807) Google Scholar Abortion-related complications can also result in severe morbidity. An estimated 6·9 million women in developing regions sought treatment for complications from an unsafe induced abortion in 2012.3Singh S Maddow-Zimet I Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012: a review of evidence from 26 countries.BJOG. 2016; 123: 1489-1498Crossref PubMed Scopus (106) Google Scholar A review of 70 studies from 28 countries estimated that at least 9% of women admitted to hospital for abortion-related reasons had a near-miss event; ie, they had complications, such as severe haemorrhage, that would have most likely resulted in death had they not made it to hospital.4Calvert C Owolabi OO Yeung F et al.The magnitude and severity of abortion-related morbidity in settings with limited access to abortion services: a systematic review and meta-regression.BMJ Glob Health. 2018; 3: e000692Crossref PubMed Scopus (37) Google Scholar Additionally, repeat abortions are common and can be reduced by integrating contraceptive services in abortion and post-abortion care services.5Jones R Jerman J Ingerick M Which abortion patients have had a prior abortion? Findings from the 2014 US abortion patient survey.J Womens Health (Larchmt). 2018; 27: 58-63Crossref PubMed Scopus (21) Google Scholar, 6Wei-Hong Z Jiong L Yan C et al.Effects of post-abortion family planning services on preventing unintended pregnancy and repeat abortion (INPAC): a cluster randomised controlled trial in 30 Chinese provinces.Lancet. 2017; 390: S29Summary Full Text Full Text PDF PubMed Google Scholar Post-abortion care has been shown to lower mortality and morbidity related to unsafe abortion, and to reduce future unwanted pregnancies by providing contraceptive servicees. Additionally, in 1994, countries around the world made political commitments to address abortion-related morbidity and mortality through the provision of quality health care.7UNReport of the International Conference on Population and Development. Cairo, 5–13 Sept, 1994. United Nations, New York1995Google Scholar Nevertheless the provision of quality post-abortion care in health-care facilities in many countries is still scarce, with access hindered by restrictions on abortion, stigma, health-care providers' negative attitudes, and low capacity of some health-care systems to provide post-abortion care.8Mutua MM Manderson L Musenge E Achia TNO Policy, law and post-abortion care services in Kenya.PLoS One. 2018; 13: e0204240Crossref PubMed Scopus (17) Google Scholar, 9Owolabi OO Biddlecom A Whitehead HS Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functions.Lancet Glob Health. 2018; (published online Nov 29.)http://dx.doi.org/10.1016/S2214-109X(18)30404-2Summary Full Text Full Text PDF Scopus (28) Google Scholar In a report published in The Lancet Global Health,9Owolabi OO Biddlecom A Whitehead HS Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functions.Lancet Glob Health. 2018; (published online Nov 29.)http://dx.doi.org/10.1016/S2214-109X(18)30404-2Summary Full Text Full Text PDF Scopus (28) Google Scholar Onikepe Owolabi and colleagues analysed data from the Demographic and Health Surveys programme obtained during 2007–17 from ten countries (Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda). Data were available from 2007–15 for all ten countries. The investigators used a signals-function approach (measuring the availability of key equipment and the ability to perform services in primary-level and referral-level facilities in each country) to assess their capacity and calculate the proportion of facilities providing post-abortion care. The investigators9Owolabi OO Biddlecom A Whitehead HS Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functions.Lancet Glob Health. 2018; (published online Nov 29.)http://dx.doi.org/10.1016/S2214-109X(18)30404-2Summary Full Text Full Text PDF Scopus (28) Google Scholar identified crucial gaps in the provision of post-abortion care in these countries. In seven of the ten countries less than 10% of primary-level facilities could provide basic post-abortion care, and in eight countries less than 40% of referral-level facilities provided comprehensive post-abortion care. The proportion of primary-level facilities with basic post-abortion care capability ranged from zero of 213 in Namibia to 136 (29%, 95% CI 25–33) of 472 in Malawi. Comprehensive post-abortion care capacity in referral-level facilities ranged from six (8%; 95% CI 5–11) of 80 in Bangladesh to 32 (58%; 45–70) in Malawi. This is the first multicountry analysis using standardised, nationally representative data to assess the capacity of health facilities that offer delivery services to provide post-abortion care. Despite some limitations of the study methods, including a bias towards facilities that provided delivery services and characterisation of the quality of post-abortion care from a health system's perspective alone, this study highlighted the large gap between political commitments to address the consequences of unsafe abortion and the capacity of health systems to provide post-abortion care. Despite the global commitment in 1994 by countries to provide quality post-abortion care,7UNReport of the International Conference on Population and Development. Cairo, 5–13 Sept, 1994. United Nations, New York1995Google Scholar in practice there is still a long way to go. Increasing the provision of such care is essential to reduce the level of abortion related morbidity and mortality. Greater emphasis should be placed on preventing unwanted pregnancies and unsafe abortion, and on improving access to post-abortion care services in health-care facilities. In fact, missed opportunities to improve women's health include those in reproductive health services and provision of modern contraceptives in postpartum care as well as in post-abortion care. I declare no competing interests. Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functionsThe capacity of primary-level and referral-level health facilities to provide basic and comprehensive post-abortion care, respectively, is low. The results highlight the gap between political commitments to address the consequences of unsafe abortion and the capacity of health systems to provide post-abortion care. Increasing the provision of good-quality post-abortion care is essential to reduce the level of abortion-related morbidity and mortality. Full-Text PDF Open Access