Recent advances in improving the effectiveness and reducing the complications of abortion

Introduction

When conducted in a legal setting and under safe conditions, abortion is an extremely safe procedure associated with few complications. US data suggest that it is as safe as or safer than most common outpatient medical procedures and safer than childbirth^1,2. Large studies typically report low rates of major complications (e.g. haemorrhage requiring transfusion, sepsis, and uterine perforation) of less than 1%^3,4. The technology and training required to provide safe abortion is quite straightforward, and both the procedure and the management of minor complications can be safely performed in an outpatient facility rather than a hospital. Evidence-based guidelines from the World Health Organization (WHO) indicate that in most cases abortion can be conducted by a wide range of healthcare providers of primary care level⁵.

Yet almost half of the 55.7 million abortions that are estimated to take place each year in the world (an estimated 25.1 million abortions) are considered unsafe (17.1 million less safe plus 8.0 million least safe)⁶. The WHO defines unsafe abortion as a procedure for terminating a pregnancy by persons who are not appropriately trained or use a non-recommended method (less safe) or both (least safe)⁶. Unsafe abortions lead to a high burden of complications, maternal deaths, and costs. Recent estimates for the global distribution of safe, less-safe, and least-safe abortions show that when the legal status of abortion is considered, the proportion of least-safe abortions is greatest in countries with highly restrictive abortion laws, most of which are developing countries⁶.

Currently, there is ongoing work to develop consensus on how to improve core outcomes of both medical and surgical abortion (such as ongoing pregnancy and incomplete abortion) and complications of abortion (haemorrhage requiring blood transfusion, infection, etc.)⁷. This commentary will focus on recent advances for improving completeness of abortion procedures and reducing complications with a focus on improving access to safe abortion, recent developments in medical abortion and surgical abortion, and what more needs to be done.

Improving access to safe abortion

Aside from legal barriers, a major obstacle to accessing safe abortion worldwide is a lack of trained providers⁵. The WHO has produced guidelines that recommend the cadre of healthcare provider who can safely and effectively undertake abortion or aspects of abortion care⁵. Involving a wider range of health workers is an important public health strategy to address the shortages of abortion providers and improve access to safe abortion for women.

The availability of medical methods of abortion, which require relatively little training and which may be safely self-managed by women at home (up to 10 weeks’ gestation) with adequate instruction⁸, has been a major advance in this respect. This has increased women’s access to safe abortion in many parts of the world⁵.

Indeed, recent data from WHO/Guttmacher suggest that in settings where abortion is highly restricted, clandestine abortions are now safer because fewer occur by dangerous and invasive methods with more taking place through abortifacient drugs^6,9. Although combination medical abortion, i.e. mifepristone followed by misoprostol, is far more effective than misoprostol alone¹⁰, mifepristone is unavailable in many highly restrictive settings, and so misoprostol alone is recommended by WHO when mifepristone cannot be obtained¹¹. Misoprostol is more widely accessible, as it is used to manage a range of conditions (e.g. gastric ulcers, miscarriage, and postpartum haemorrhage). It is also less expensive. However, women who take misoprostol without access to advice from a trained provider can also take risks to their health. There is evidence that trained community workers who distribute misoprostol in restrictive settings can play an important role in improving safety¹². In addition, in restrictive settings, telemedicine is helping to improve women’s access to medical abortion over the internet via not-for-profit organisations such as Women on Web, Women Help Women, and Safe2choose. These organisations provide an online consultation for women and information on how to take the medications, the risks, and the signs that indicate the need to seek medical assistance¹³. Women receive the medication by post in a discrete unmarked package some days to weeks later, depending on where they live. Women on Web report that in the first 10 years of their internet service, over 50,000 women accessed medical abortion from them in this way¹⁴. Studies generally indicate that this means of providing medical abortion in the first trimester is associated with high rates of effectiveness and low rates of self-reported complications^13,15, although it should be noted that in studies in highly restrictive settings loss to follow up can be significant. Recently, there has also been growing interest in the use of telemedicine to expand access to medical abortion in settings where abortion is legally available but where it may be difficult to access an abortion provider^16,17.

Recent developments in medical abortion

Recent developments in surgical abortion

What more needs to be done?

Countries with restrictive abortion laws have higher unsafe abortion rates than those with liberal laws⁶. The liberalisation of abortion does not lead to more abortions but makes abortion safer, lowering the costs of treating complications and saving women’s lives⁶. The legalisation of abortion in countries such as Romania, Nepal, and South Africa was followed by dramatic declines in maternal mortality and morbidity associated with unsafe abortion^34,35.

Abortion stigma, and associated secrecy and shame that surround abortion, is a major factor behind unsafe abortion in many parts of the world^5,36. Stigma prevents women from seeking help when they suffer a complication after an illegal abortion, and this decision to forgo care may lead to death or severe disability. Even in settings where abortion is legal, stigma may result in women delaying an abortion. Such delays push abortions into more advanced gestations, sometimes beyond the legal gestational limit. Stigma also affects providers, who often suffer low morale, lessened prestige, and even ostracism for providing this essential service. Moreover, strong criticism may deter qualified healthcare workers and those in training from undertaking abortion care⁵. Strategies to address and lessen abortion stigma within our societies and the healthcare professions are therefore necessary.

Given that the vast majority of induced abortions occur because of an unintended pregnancy, it is essential to ensure good access to effective methods of contraception. Making modern methods both affordable and readily available is essential, as is contraceptive information as part of sexuality and relationship education for all. Emergency contraception needs to be available for when regular contraception fails or is not used. Recent data indicate that whilst the numbers of women of reproductive age in developing countries who have an unmet need for modern contraception (i.e. they wish to avoid pregnancy but are not using a modern contraceptive method) have declined in recent years, they remain high at 214 million women⁹. These women account for 84% of all unintended pregnancies in developing regions.

Fertility can resume quickly after abortion. WHO guidelines recommend that contraceptive counselling and method provision be integrated into comprehensive abortion care^5,11. This includes the most-effective long-acting reversible methods of contraception (LARC) such as the implant and intrauterine contraception, which can be safely initiated immediately after an abortion¹¹. For women having a combination medical abortion, the implant can be inserted at the time of mifepristone administration, and intrauterine contraception can be inserted as soon as expulsion of the pregnancy occurs^37–39. In addition, for women who want to use a LARC method, receiving one at the time of the abortion is associated with higher uptake and fewer subsequent unintended pregnancies than getting one at a later visit^37,40,41.

Conclusion

Abortion is an extremely safe procedure and, when it is conducted under safe conditions, complications are uncommon. Liberalising abortion laws around the world is essential for safe abortion but needs to be accompanied by health policies that support implementation of the law, increase the availability of trained providers, and work to remove the stigma of abortion in our societies. Finally, improving the access, availability, and affordability of effective methods of contraception will prevent more unintended pregnancies and thus the abortions, and associated complications, that follow.