health systems. Presentations at the meeting addressed many facets of unsafe abortion, from an evidence-based global overview to medical advances in treating complications to regional perspectives and priorities. Participants documented the gravity and global reach of unsafe abortion and called for action to reduce unsafe abortion and its consequences for women and society. Until unsafe abortion is eliminated, women will continue to suffer the consequences of abortions performed under unsafe conditions. It is hoped that this collection of papers, with their calls for research and action, will stimulate the international public health community to address unsafe abortion and reduce the suffering experienced by millions of women who are not able to access safe abortion services. This volume is being published by the Guttmacher Institute, the leading independent think tank on sexual and reproductive health. Guttmacher conducts research and engages in public education on unsafe abortion, and is currently collaborating with WHO and the World Bank to estimate and disseminate information on the incidence of abortion worldwide. It believes the papers included in this report advance understanding of the toll of unsafe abortion and provide valuable insight into the research and action needed to effectively address this problem. Ina K.Warriner and Iqbal H.Shah PREFACE A-Intro.indd 8 09/02/2006 10:44:47 ix This volume brings together the many contributions of the participants attending the meeting on "Priorities and Needs in the Area of Unsafe Abortion", organized by the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) in August 2000. We are indebted to the participants, including members of HRP's Specialist Panel on Social Science and Operations Research in Reproductive Health, who brought with them their commitment to eliminating unsafe abortion, their passion for improving women’s health, and their expertise and ideas for addressing the problem of unsafe abortion. It is their dedication to reducing the burden of unsafe abortion on women’s lives and their calls for action that are reflected in these pages. Thanks are also due to Dr Wendy Baldwin who so ably chaired the meeting and expertly guided discussions on the many facets and complexities surrounding abortion. We owe a significant debt of gratitude to the Ford Foundation for generously supporting the publication of this volume through a grant to the Guttmacher Institute. We would also like to acknowledge the contribution of Mr Mauro Bernardi who designed the cover and layout of the volume. Ina K. Warriner and Iqbal H. Shah Acknowledgements A-Intro.indd 9 09/02/2006 10:44:47 A-Intro.indd 10 09/02/2006 10:44:47 1 Unsafe abortion: an overview of priorities and needs Ina K.Warriner 1 ABSTRACT Unsafe abortion is a significant yet preventable cause of maternal mortality and morbidity in developing countries. This report contains the papers submitted to an interdisciplinary consultation convened by WHO to assess the problem of unsafe abortion globally and to identify a research agenda aimed at reducing unintended pregnancy, unsafe abortion, and the resultant burden on women, their families, and public health systems. Experts at the consultation reviewed the available evidence on unsafe abortion, examined the factors that perpetuate the problem, and identified both opportunities for preventing unsafe abortion and constraints on prevention. Participants addressed the theoretical and medical issues relating to research on unsafe abortion and outlined regional priorities for the prevention of unsafe abortion. Both long-standing and emerging issues relating to research on unsafe abortion were discussed. 1 1 UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, 1211 Geneva 27, Switzerland. B-Chap 1.indd 1 07/02/2006 13:31:34 2 INA K.WARRINER Background Each year, an estimated 210 million women throughout the world become pregnant and about one in five of them resort to abortion. Out of 46 million abortions performed annually, 19 million are estimated to be unsafe (1). WHO defines unsafe abortion as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both (2). The burden of unsafe abortion lies primarily in the developing world; the highest rates are in Africa and in Latin America and the Caribbean, followed closely by South and South-East Asia. At the opposite extreme, the rate of unsafe abortion in Europe and North America is negligible. Where access to safe abortion is restricted, complications from unsafe abortion lead to morbidity and are a major cause of maternal deaths. Globally, it has been estimated that some 68 000 women die each year as a consequence of unsafe abortion, and 5.3 million suffer temporary or permanent disability (3). The public health burden is greatest in the developing world. The root cause of women seeking an abortion is the persistence of unintended pregnancies, which in turn reflects the failure of family planning programmes to meet the contraceptive needs of all women at risk of an unintended pregnancy. For