Wednesday, July 20, 2016 | News

Expert group urges updated definition and measurement of unsafe abortion

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

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.

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