Expert group urges updated definition and measurement of unsafe abortion

Wednesday, July 20, 2016

image of unsafe abortion continuum

A group of reproductive health experts has recommended that the World Health Organization (WHO) update the way it defines and measures “unsafe” abortion.

Since the 1990s, WHO has defined unsafe abortion as those performed either by individuals lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. Operationally, however, unsafe abortion has been defined as illegal abortion.

In an article published in the International Journal of Gynecology & Obstetrics, the expert group writes that, “In the past decade…the incidence of abortion by misoprostol administration has increased in countries with restrictive abortion laws. Access to safe surgical abortions has also increased in many such countries. An important effect of these trends has been that, even in an illegal environment, abortion is becoming safer, and an updated system for classifying abortion in accordance with safety is needed.”

The expert meeting was convened in London in 2014. The WHO had, at that time, recently issued an editorial statement proposing that the safety of abortion should be characterized along a continuum of risk, rather than as a binary measure of “safe” or “unsafe.” The expert meeting used that proposal as a starting point for developing its insights.

Ipas Vice President Janie Benson, who directs Ipas’s research and evaluation work, was among the expert group. “The recommendations from this expert group are a major step forward in the measurement of abortion in a fast-changing global environment. Realizing these recommendations will require creative use of methodologies, commitment of resources and prioritization of abortion measurement,” she says.

In the journal article, the group notes that many factors other than legality affect the safety of abortion—factors such as the qualifications of the person performing the abortion, the method of abortion, the social setting, the presence of complications, and the severity of complications.  A reasonable approach, the group says, is to consider all abortions that do not comply with WHO technical and policy guidelines as unsafe, and to further differentiate unsafe abortions according to their outcomes, with those resulting in severe complications or death classified as “most unsafe.” Once a range of safety categories is established, research to quantify the number of abortions in each category would be needed, in addition to qualitative research to assess how factors such as abortion stigma and the criminalization of abortion affect the well-being of women seeking abortion.

The group also noted that even abortions that are performed in accordance with recommended clinical guidelines can carry additional risks if they are performed in settings where abortion laws are highly restricted or highly stigmatized: “In such contexts, women might delay seeking care and obtain an abortion at a fairly late stage and under stressful conditions, thereby increasing the risk of physical or psychological complications. Furthermore, they might not receive information or counseling, including family planning counseling…”

Updating the classification and measurement of unsafe abortion not only has the potential to encourage more investment in programs and policies to reduce the incidence of unsafe abortion, the experts wrote, it “is essential if we are to ensure that preventing unsafe abortion is on the global public health agenda.”

Images adapted from Fig.1 Illustrative example of conceptual definitions of abortion safety classifications and measurement approach, Insights from an expert group meeting on the definition and measurement of unsafe abortion, International Journal of Gynecology and Obstetrics, 134 (1): 104-106.