particular circumstances are very local. That says to me that researchers – and the agencies that fund researchers – must ensure that their work derives from the community, involves the community, and can be used by the community. Another observation is the resolve with which women seek to end unwanted pregnancies. Unsafe abortion poses a risk across the lifespan. Adolescents facing an unintended pregnancy before finishing school or finding a stable partner are most Foreword A-Intro.indd 5 09/02/2006 10:44:47 vi likely to seek an end to the pregnancy. Adolescents are also at high risk of forced intercourse, perhaps the worst path to an unwanted pregnancy. These are young women who are likely to have fewer financial resources and a poor understanding of an often punitive health care system; hence the risks and potential complications they face are great. Consequences may include a lifetime of infertility; a condition that can affect their ability to marry and achieve full adult status in some settings. But unsafe abortion knows no age boundaries – many an older woman has believed her reproductive time had passed only to be surprised by a pregnancy! Contraceptive vigilance may decline along with the perceived risk of pregnancy, but that is a calculus that is easy to get wrong. The years a woman may be anticipating as a grandmother may be taken from her – and her family – if she faces death or infection from an unsafe abortion. The woman, who would be a source of support for her children and grandchildren, suddenly faces an imperiled future. The risks of unsafe abortion are not just to the woman involved. Of course, risks to her health jeopardize her family, but the costs of unsafe abortion are carried by the whole of the society. How many other lives could be saved if fewer medical resources were applied to safe abortion rather than to redressing the ravages of unsafe abortion? What message might we take from this call to prevent unsafe abortion? I urge the readers of this book to continually remind themselves of the basic message of unsafe abortion: look at the lengths women will go to end an unwanted pregnancy. Let our commitment be as great to ensure that women do not face unwanted pregnancies and that when they do, they do not have to put their very lives in jeopardy. Wendy Baldwin FOREWORD A-Intro.indd 6 09/02/2006 10:44:47 vii Unsafe abortion is a commonly neglected reproductive health care problem in developing countries, yet it poses a serious threat to the health of millions of women during their reproductive lives. Until unsafe abortion and its consequences are eliminated, complications from unsafe abortion will remain a major cause of maternal mortality and morbidity. Defined by the World Health Organization (WHO) as the termination of an unintended pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both, unsafe abortion remains a frequently unacknowledged public health burden of substantial proportions. The brunt of unsafe abortions occurs primarily in the developing world. Although most women seeking abortions are married or in stable unions and already have several children, an increasing proportion of those seeking abortions are unmarried adolescents, particularly in urban areas. However, throughout the developing world, countless women are barred from access to safe abortion services due to a combination of social, economic, religious, and policy factors. The 1994 International Conference on Population and Development (ICPD) highlighted the pressing need for work on unsafe abortion, and, 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 8.25 of the Programme of Action). It further declared: “In circumstances where abortion is not against the law, such abortion should be safe.” (Paragraph 63i). Although a number of developing countries have liberalized abortion laws, much work remains to be done to ensure that unsafe abortion becomes a public health concern of the past. Relatively few studies have examined unsafe abortion and its consequences in the wake of ICPD’s call for action. Consequently, there is a clear and pressing need to define a research agenda and identify advocacy strategies to reduce unsafe abortion. To achieve the overall goal of eliminating unsafe abortion, it is necessary to understand the factors behind the persistence of unsafe abortion and the opportunities and barriers to preventing unsafe abortion. Preface A-Intro.indd 7 09/02/2006 10:44:47 viii With this goal in mind, the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction under the leadership of its Director, Dr Paul F.A. Van Look, convened a consultation on “Priorities and Needs in the Area of Unsafe Abortion” in Geneva, Switzerland, in August 2000, to bring together internationally prominent researchers from a variety of disciplines to assess the global status of unsafe abortion and to identify a research and action agenda to reduce unsafe abortion and its burden on women, their families, and public