the growing number of women and men of reproductive age who wish to regulate their fertility and have fewer children, there is a need for correct and consistent use of effective contraceptive methods. However, problems such as difficulties in access to preferred methods of contraception, incorrect or inconsistent use of contraceptive methods, and potential contraceptive method failure are not easily resolved and may lead to unintended pregnancies. Other reasons for unwanted pregnancies include forced or unwanted sexual intercourse and a lack of women’s empowerment over sexual and reproductive matters. Societal norms, economic conditions, legal obstacles and other systemic factors are likely to have a profound impact on women’s recourse to abortion and especially unsafe abortion. Poverty, for example, is an important determinant in the decision to seek an abortion when women consider the financial consequences of an unintended pregnancy. Broadly speaking, where there is no legal restriction, abortion services are likely to be safe. In these settings, the abortion is performed in a regulated medical setting and the providers are properly trained. In contrast, where abortion laws are highly restrictive, women turn to clandestine providers with a high risk of incurring a serious or life-threatening complication. B-Chap 1.indd 2 07/02/2006 13:31:34 3 UNSAFE ABORTION : AN OVERVIEW OF PRIORITIES AND NEEDS However, there are significant exceptions to this generalization and the relationship between the legality of abortions and the safety of service provision is not always straightforward. Illegal abortions are not necessarily unsafe, legal abortions are not necessarily safe, and clandestine abortions occur in countries where abortion is legal and free of charge. Clandestine providers may be skilled in abortion provision and provide high quality abortion care in some cases, while government certified providers may offer poor service and quality of care so that women turn to untrained abortion providers who may be more respectful of confidentiality and privacy. An example of the latter situation is India, where abortion is legal and provided free of charge in government authorized clinics but significant numbers of abortions continue to take place in uncertified settings, a large proportion of which are unsafe. Additional factors related to quality of care and access to services contribute to high levels of unsafe abortion in India, including a limited number of government certified abortion clinics in rural areas, compelling women to seek out other providers (4). In regions where abortion is highly restricted, the private sector plays an important role in provision of safe abortions for women who can afford it. Although costly and therefore only accessible to women with the means to pay, clandestine abortion providers (such as well-trained doctors and midwives) may offer a safe abortion service, including postabortion care if there should be complications. The 1994 International Conference on Population and Development (ICPD) outlined the issues and challenges for work in the area of unsafe abortion. In its Programme of Action, it urged governments and other relevant organizations “...to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family planning services” (Paragraph 63i of the Programme of Action). It further states: “Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. Post-abortion counselling, education and family planning services should be offered promptly, which will also help to avoid repeat abortions” (Paragraph 63i). Subsequent conferences, including the Fourth World Conference on Women (FWCW) in 1995, the ICPD + 5 meeting in 1999, and the Beijing + 5 meeting in 2000 continued to call for the provision of safe abortion services where they are not against the law. B-Chap 1.indd 3 07/02/2006 13:31:34 4 INA K.WARRINER The Special Programme on Research, Development and Research Training in Human Reproduction was established by the World Health Organization in 1972 and has maintained an important role in research on preventing unsafe abortion and its consequences for maternal mortality. The work on preventing unsafe abortion at WHO is directed at ensuring that, where abortion is legal, the procedure should be safe. Despite a global trend toward the liberalization of abortion laws, unsafe abortion remains an important unresolved reproductive health concern and the need to identify priority research areas continues. Interventions such as the Safe Motherhood Initiative have been successful at reducing maternal mortality in some countries; however, until unsafe abortion is eliminated, complications from unsafe abortion remain a major cause of maternal mortality. To achieve the overall goal of eliminating unsafe abortion by improving the safety of