and nonpoor women to use an untrained provider or self-induce. 4.1 FIGURE % of women having an abortion All Poor Nonpoor Rural Urban 18 31 51 9 29 62 29 35 36 13 32 55 30 32 38 Doctor Nurse/midwife Untrained provider/ pharmacist/ woman herself Type of provider: n) Midlevel providers are nurses and nurse midwives, and other nonphysician providers whose titles vary by country, including auxiliary nurses and auxiliary nurse midwives, advanced associate clinicians and associate clinicians, among others. 22 GUTTMACHER INSTITUTE Traditional abortion methods can be damaging to women’s health general, a later abortion is riskier for the woman’s health than an earlier one,36 and any complications that occur may be magnified and even harder to manage in low-resource settings106 (seeChapter 5). Studies in a few countries show that untrained abortion providers—including pharmacists or market sellers, who may know little about misoprostol—are usually more plentiful, easier to find and less expensive than trained and informed ones.37,107,108 Reliance on poorly informed providers often means that the resulting abortion or advice is more likely to lead to an incomplete abortion.109 Moreover, if a first abortion attempt fails, a woman has to start again with another provider at an increasingly later stage of pregnancy. In addition to being riskier, abortions at later gestations tend to cost more because they require more-advanced training and specialized equipment (or in their absence, a traditional provider who is willing to perform a more difficult procedure). And if a woman cannot afford to go to a trained professional, she may resort to more traditional methods and risk more severe complications as the pregnancy advances. Available data from legally restrictive settings show increases in the use of vacuum aspiration, which is a less-invasive surgical technique than D&C. Perhaps even more important, use of misoprostol alone (the second drug in the combination protocol) has risen substantially.37,63 In countries that legally restrict abortion, mifepristone (the first drug) is either prohibitively expensive or unavailable altogether. Misoprostol, which is widely registered to treat gastric ulcers (and less-widely registered for obstetric indications), is far less expensive than mifepristone and much more available110,111 (see misoprostol-only box). Information on trends in abortion methods used in legally restrictive settings is available for just three countries: Colombia and Mexico (between 1992 and 2008), and Pakistan (between 2002 and 2012). Data on misoprostol use were not collected for the earlier years in Colombia and Mexico because its use was considered to be very limited at that time. According to surveys of health professionals, an estimated one-half of all abortions in Colombia in 2008 and nearly one-third in Mexico in 2007 were done using misoprostol alone. At the same time, the proportions of procedures performed by physicians and untrained providers have declined, which suggests that reliance on surgical methods and unsafe traditional methods have both dropped.112 In Pakistan, the proportion of health professionals who responded that misoprostol was commonly used was much higher in 2012 than in 2002, and this change was more evident in urban areas than in rural areas.113 Comparable data are available on how abortions are carried out in 10 countries where use of misoprostol for inducing abortions was considered to be relatively low at the time of data collection (2009–2015). These data suggest that an average of 18% of all abortions are performed by physicians, and 31% by such midlevel professionals as nurses and midwives (Figure 4.1, page 21).114 The remainder—about half—are provided by untrained providers or are self-induced (mainly with methods other than misoprostol); the latter group includes the use of various unsafe traditional methods (see traditional methods box). The pattern of inequity in access to safe abortion, as seen through the lens of urban-rural residence and poverty status, is consistent across countries Women and untrained providers use many types of traditional and nonmedical methods to end unintended pregnancies. Not only do these methods often fail, they can lead to severe complications. The main categories of these methods, with examples from studies published over the past 10 years, are summarized below. ■ Inserting into the vagina or cervix a catheter or other foreign object, such as cassava sticks, parsley stems, tree roots, crushed herbs, ground seeds, chicken bones, pencils, metal probes, wires, coat hangers, knitting needles, bicycle spokes, crushed bottles, potassium nitrate (saltpeter) or potassium permanganate tablets.1–8 ■ Introducing liquids into the vagina, such as saline solutions (saline instillation), concentrated herbal concoctions prepared with water or alcohol, soapy solutions, detergent or bleach.1,2,7 ■ Drinking alcohol, detergent, laundry bluing, fabric softener, bleach, acid, methylated spirits, castor oil, turpentine, tea brewed with livestock feces, blood tonics, concentrates of traditional plants2,4,9–15 or, in South Africa, Dutch remedies (i.e., alcohol-based products containing small amounts of active ingredients).13 ■ Ingesting pharmaceutical products, including aspirin, painkillers, flu medicine, laxatives, chloroquine,