Information for policymakers / Updated in 2013

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1. Presentation

2. Data on abortion globally and the public health issues

“Unsafe abortion endangers health in the developing world, and merits the same dispassionate, scientific approach to solutions as do other threats to public health. Although the remedies are available and inexpensive, governments in developing nations often do not have the political will to do what is right and necessary. The beneficiaries of access to safe, legal abortion on request include not only women but also their children, families, and society—for present and future generations.” [1]

Improving maternal health and halving the maternal mortality ratio by 2015 is one of the eight Millennium Development Goals (MDGs) endorsed by 189 countries in September 2000. Universal access to reproductive health was added to this goal in 2005.

Estimates by the World Health Organization (WHO) show that up to 358,000 women are dying each year due to complications of pregnancy and/or childbirth. Most die because they have no access to skilled routine and emergency obstetric care. [2] Deaths from complications of unsafe abortion constitute 13% of maternal deaths, but this ranges from almost no deaths in some countries to over 30% or more in others. With the world population growing and in the absence of changes to make abortions safe, the numbers of unsafe abortions increased from 19.7 million in 2003 to 22 million in 2008, almost all in developing countries. [3]

WHO defines unsafe abortion as a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. [55] However, as a recent WHO publication states “While the definition seems to be linked to the process, characteristics of an unsafe abortion touch on inappropriate circumstances before, during or after an abortion”. [2] Singh et al. add this crucial point: “Whether abortions are performed within or outside of the prevailing legal framework, the medical standards and safety of the procedure vary. When performed within a legal framework—in properly equipped and regulated health facilities, by qualified health professionals with specific training in abortion—the procedure is extremely safe. However, if a country’s abortion laws are not implemented equitably and the necessary resources and skilled providers are not equally available to all women, some abortion procedures may be unsafe, even where abortion is legally permitted under broad criteria. [6]

Between 1995 and 2003, the abortion rate (number of abortions per 1,000 women) declined globally. In contrast, the rate of unsafe abortions fell only slightly, from 15 per 1,000 women in 1995 to 14 per 1,000 women in 2003. Hence, the increase in the number of unsafe abortions was mainly due to the growing population of women of reproductive age, [2] and the proportion of all abortions that were unsafe increased from 44% to 47%. [4], [5] The 2011 WHO report [2] also stated that: “It is likely that the numbers of unsafe abortions will continue to increase unless women’s access to safe abortion and contraception – and support to empower women (including their freedom to decide whether and when to have a child) – are put in place and further strengthened."

Worldwide, 48% of all induced abortions are unsafe. In developed regions, nearly all abortions are safe (92%), whereas in developing countries, more than half are unsafe (55%). In Latin America and Africa, more than 95% of abortions are unsafe, and 60% of abortions in Asia (excluding Eastern Asia). [4]

Although deaths when abortion is safe are less than 1 per 100,000 abortions, the mortality rate is far higher where unsafe abortions are the rule: 350 deaths per 100,000 abortions in low‐resource countries overall and, specifically in Africa, 680 per 100,000 procedures. Global estimates of the disability burden of unsafe abortion show a loss of approximately 5 million years of productive life each year, representing an estimated 14% of all annual disability from pregnancy‐related conditions.[6]

Yet, unsafe abortion and associated morbidity and mortality are completely avoidable. The rate and severity of abortion complications are directly related to the poor quality of abortion care, including: absence of a skilled abortion provider and adequate health care facilities; use of hazardous substances or methods for abortion; stigma and socio-economic barriers preventing women from seeking a safe abortion; and lack of post-abortion care for any complications. [2], [7]

The treatment of complications of unsafe abortion is expensive, creating a critical cost burden for health systems. For women, serious complications may lead to long- term health problems, including chronic pain and infertility. In addition, unsafe abortion translates into indirect economic costs related to loss of productivity among women who survive serious complications, which also has an impact on children and families. [8]

Advances in medical technology have made abortion one of the safest possible clinical procedures, with both the surgical and medical methods endorsed by WHO. All the evidence shows that mortality from complications of unsafe abortion almost disappears when abortion is decriminalised and safe abortion services are made available. [9] In many countries, however, laws and policies regulating access to abortion and abortion services date as far back as the 19th century. These laws and policies and the outdated abortion services that are the result of them need updating so as to ensure that safe abortion methods are affordable, available and accessible.

Policy makers need to be aware that medical abortion, which is in the form of two types of pills used together, is safe and effective, as well as a confidential and non-invasive means of delivering both abortion and post‐abortion care services. It is used for both first and second trimester abortions, as well as very early abortions. Early medical abortion is highly cost effective, in large part because it can be provided at primary care level by a range of mid‐level health care staff, requiring minimal infrastructure. Therefore, expanding access to medical abortion is a critical aspect of any intervention aimed at making all abortions safe.

Safe, legal abortion services should be part of reproductive health services for women, along with the provision of contraception, emergency contraception, and post-abortion care. Together, these services will reduce unintended and unwanted pregnancies and lead to a huge improvement in women's health and make it possible for them to decide the number and spacing of their children. This is a crucial part of ensuring universal access to reproductive health, contributing to MDG5 and many other commitments the international community has endorsed since the 1985 World Conference on Women in Nairobi. [10], [11]

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3. Why policy makers should take action

Policy makers are in a position to influence their country's policies on abortion. Given their responsibility in setting the agenda for priorities in health policy and in the design, implementation and evaluation of such policies, as well as in the framing of national and local norms and regulations, they can help to improve access to safe abortion.

This section describes how to improve policies for making abortion safer, as well as how to make medical abortion an integral part of reproductive health and safe abortion services. It does so taking into account both legally restrictive contexts and those in which abortion is legal but still unsafe. It shows why legal abortion is essential from a public health and women’s/human rights perspective, and gives basic information on policy matters related to safe abortion. Finally, it responds to some frequently asked questions about proven successful strategies for expanding access to abortion services, and provides an action agenda for policy and service delivery changes and law reform.

So, why should policy makers take action?

There is growing recognition internationally that access to safe abortion is a serious public health issue and also an issue of women’s human rights.

The international and regional human rights systems have a growing legal and political importance (Box 1). In recent years, many countries have given constitutional status to human rights treaties and/or have made them part of their national laws. Additionally, certain national courts and parliaments have begun to recognize and acknowledge the legally binding nature of the decisions of international human rights bodies. The human rights framework can be used as a means of holding States accountable for their policies and as a guideline for the development of health care standards, among other uses. [12]

Box 1: The international human rights system [13], [14]

This system comprises one international human rights body (UN) and three regional ones (European, American and African). Each has developed a set of documents – ranging from international treaties and resolutions to political statements, which express the human rights commitments that States have endorsed and for which they can be held accountable. These documents are a powerful tool for the advancement of women´s rights and can be used both by human rights bodies, civil society organizations and political authorities and representatives for protecting and fulfilling women's access to safe abortion.

The implementation of human rights treaties and other human rights instruments is monitored by treaty-monitoring bodies and is a commitment and an obligation on the States that have ratified them.

This century has also seen groundbreaking decisions the regional and international human rights bodies as well as from from national courts and legislatures around the world that provide increasingly robust protection for women’s health and reproductive self-determination. For example, there is a growing interest among international and regional human rights bodies in maternal mortality and morbidity, and safe abortion, both as public health and human rights issues. These bodies have called upon governments to ensure women’s access to maternal health care and to abolish social practices that negatively impact women’s health. They have also recommended that States parties implement measures to address the causes of maternal mortality and morbidity. Moreover, women’s right to abortion in certain circumstances has also become grounded in a broader range of fundamental human rights. [15]

On October 24, 2011, the Special Rapporteur on the Right to the highest attainable standard of Health, Anand Grover, released a ground-breaking report. This report states that: “Criminal laws penalizing and restricting induced abortion are the paradigmatic examples of impermissible barriers to the realization of women’s right to health and must be eliminated. These laws infringe women’s dignity and autonomy by severely restricting decision-making by women in respect of their sexual and reproductive health.”

Barriers to safe abortion are a violation of women´s human rights

Women’s right to access safe, legal abortion involves a range of human rights – the right to life; health; non-discrimination; equality; liberty; personal security; freedom from cruel, inhuman, or degrading conduct; privacy; freedom of thought and religion; information; and the right to enjoy the benefits of scientific progress – all of which have been recognized under different Human Rights Treaties.

There are also other international consensus statement such as the Programme of Action of the International Conference on Population and Development (ICPD), which set out international and national commitments but are non-binding agreements. Since the 1990s, these global agreements reflect the increasing support that the international community gives to sexual and reproductive rights, and are frequently used for advocating for legislative and policy reforms at national level. [16]

Since 2000, Human Rights bodies have made recommendations to States parties urging them to guarantee women rights in relation to the consequences of rape, unwanted pregnancy and unsafe abortion. [17] They have called for the amendment of laws that criminalize abortion when women‘s life or health are at risk and in cases of rape. And they have identified denying a woman an abortion when her life or health is at risk, if the pregnancy is a consequence of rape or incest, or when there is fetal impairment as human rights violations. Several treaty-monitoring bodies have also stated that restrictive abortion laws may lead to unsafe abortions which jeopardize women’s life and health. Finally, they have highlighted the responsibilities of governments to implement specific actions to protect adolescents who need safe abortions; and to assure women’s right to safe abortion services where legal.

Unsafe abortion has high costs for both women and society

Unsafe abortions have a high cost. Women suffering from complications of unsafe abortion may experience long-term consequences to their health or they may die if they do not receive appropriate and timely treatment. These outcomes in turn generate other costs, such as loss of productivity, which will be borne not only by affected households but more broadly, by society as a whole. For all developing regions, the economic impact of abortion-related mortality, estimated from the cost of premature death due to unsafe abortion in terms of lost productivity, has been estimated to be about US$28 million per year. [18]

Moreover, an estimated 220,000 children worldwide lose their mothers every year due to abortion-related deaths; [19] these children are more likely to receive inadequate health care and social services such as education and are more likely to die at an early age than children with two parents. [20] , [21]

The cost of providing safe abortion services to health systems must be contrasted with the cost of treating complications of unsafe abortion, the latter most commonly in secondary or tertiary level facilities. In 2008, complications of unsafe abortion were causing 47,000 deaths globally each year. [2] Access to timely, good quality post-abortion care remains limited in many less developed countries. Among the estimated eight million women who annually experience complications of unsafe abortion requiring medical treatment, only five million receive such care.[6]

Most post-abortion care is provided by public health facilities. [22] The costs of treating complications from unsafe abortion represent a significant financial burden on overstretched public health care systems in the developing world. Although actual data are limited, studies have estimated that in Africa and Latin America, health system costs of post-abortion care range from US$159 million to US$476 million, or an average of US $277 million, per year. [23] This is in addition to the estimated US$490 million spent annually in Africa and Latin America on treating obstetric emergencies. [24]

Two recent studies, one in Mexico (Box 2) and the other in Nigeria and Ghana, have shown that the provision of safe abortion is not only cost-effective and results in reduced complications, decreased mortality and morbidity, but also leads to substantial cost savings compared to unsafe abortion. [25], [26]

Box 2: Mexico City experience with safe vs. unsafe abortion costs [27]

In 2005, an assessment of abortion outcomes at a mix of public and private facilities and costs to the health care system in Mexico City prior to the legalization of abortion found the following. The average cost of an abortion with dilatation and curettage (D&C) was US$143, while for manual vacuum aspiration it was US$111 in three public hospitals and US$53 at a private clinic, and US$79 for medical abortion with misoprostol alone. In contrast, the average cost of treating severe abortion complications at the public hospitals ranged from US$601 to over US$2,100. And the latter excludes the cost to the woman of the abortion that was unsafe. The study concludes that providing manual vacuum aspiration and early abortion with misoprostol could reduce government costs by 62%, with potential savings of up to US$1.6 million per year.

Access to legal abortion services reduces maternal mortality and decreases the rate of abortion deaths

Lack of access to contraception increases the incidence of abortion, but legal restrictions on abortion do not lower its incidence. For example, the abortion rate is 32 per 1,000 women in South America and 28 per 1,000 women in Africa, where abortion is illegal in many circumstances in most countries. In contrast, it is 2 per 1,000 women in Europe, where abortion is generally permitted on broad grounds. The lowest abortion rates in the world are in Western and Northern Europe, where abortion is accessible with few restrictions. [2]

Legal prohibition does not deter women from having an abortion, as a 2012 study by the Guttmacher Institute showed. [28] However, laws regulating access to abortion do have an effect. Laws can be more or less restrictive. They may not permit abortion under any circumstances. This is the case in only a few countries. They may permit abortion only in specific circumstances, such as when a woman’s life or health is at risk, in cases of fetal abnormality, or in cases of rape or incest. While these are crucial grounds for legal abortion, most abortions do not fall under these grounds. Moreover, current interpretations of what constitutes a health risk do not take into account a comprehensive definition of health, which includes both mental health and social well-being. [29] Therefore, this legal ground may be used in a more restrictive way than it should be. Thus, in countries with only some or even all of these grounds, access to safe abortion may still be limited. In contrast, laws that permit abortion because contraception has failed, on broad socioeconomic grounds, and in order to protect a woman’s existing children and her well-being, and above all, laws that allow abortion at a woman’s request, cover women's most common reasons for seeking an abortion, and make access to safe abortion possible. See the Center for Reproductive Rights' Map of Abortion Laws. [30]

The 2011 UN Women Report “Progress of the World´s Women: In Pursuit of Justice” stated that 67% of countries in the world (129 out of 192) allow abortion only under certain circumstances, such as risk to life or health, 44% allow abortion at a woman´s request (at least in the first trimester of pregnancy, while five countries (Chile, El Salvador, Nicaragua, Malta and Dominican Republic) do not allow abortion under any circumstances. [31]

All the evidence shows that abortion is safest when a woman’s request for an abortion, no matter what the reasons, is met, both in law and policy. [32]

Box 3: The impact of the removal of legal restrictions

Historically, the removal of legal restrictions on the provision of abortion has led to a decrease in maternal mortality and morbidity that are due to complications of unsafe abortion. [33], [34]

In Romania, from 1957 onwards, there was widespread access to legal abortions on request, which led to a decline in deaths from unsafe abortion to as low as 20 per 100,000 live births by 1960. [35] However, mortality began to rise again as pro-natalist inspired restrictions on abortion under Ceausescu, imposed in 1966, began to take effect. By 1989 abortion mortality had risen to 126 deaths per 100,000 live births, constituting 87% of all maternal deaths. When Ceausescu was deposed in 1989, the immediate change in the law again reversed this trend. Mortality fell to 68 within the first year, and by 2002, mortality from unsafe abortions was as low as 9 per 100,000 live births. [36]

In the United States, within five years after the Supreme Court changed the law in 1973, deaths due to unsafe abortion decreased by 85%. [37]

In Nepal, abortion was legalized in 2002. By 2008, working with civil society partners, the Government had trained nearly 500 abortion providers throughout the country [38] and in 2009, a fund was created to ensure that rural and poor women could access these services, and to educate both providers and the public on the law. The maternal mortality rate nearly halved between 2001 and 2006, which was in part attributed to the increased availability of safe abortion and reproductive health services. [39]

In South Africa, abortion became legal and available on request in 1997. [40] Since then, the resulting favourable environment has increased women’s access to family planning, abortion, and post-abortion care services in the country. After the law was passed, abortion-related deaths dropped by 91% between 1994 and 2001. [41]

Law reform is a necessary but not sufficient condition for decreasing the incidence of unsafe abortion mortality and morbidity, however. India is an example where, although abortion has been legally permitted since 1972, abortion services have still not been institutionalized on a universal basis and unsafe abortions are still rife. [42] Thus, steps must also be taken to improve access to safe and affordable abortion services, so that they are available, accessible and affordable, taking into account the disadvantaged situation of the poorest women. In addition, women need to be informed of their right to obtain an abortion and where services are located. Last but not least, abortion services must provide a high quality of care, including contraceptive provision and where possible, a choice of the abortion methods approved by the World Health Organization (WHO). [43]

Legalization of abortion has a positive impact on women´s health. The following figure from WHO illustrates the relationship between deaths due to unsafe abortion and legal grounds, showing that the more legal grounds for safe abortion, the fewer the abortion-related deaths and the lower the mortality, as compared to the countries where grounds for abortion are more restricted. [44]

Source: [41]

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4. Abortion law reform: current situation and trends

At present, most countries, even those with relatively liberal laws on abortion, continue to have outdated Penal Code provisions in place, containing the circumstances in which abortion is still a crime. [29] However, a noticeable trend worldwide is showing that these penal code provisions have been supplemented or replaced by public health regulations, court decisions, and other laws and norms that authorize the provision of reproductive health care, including abortion services. Therefore, characterizing a country’s abortion laws and regulations may require the consideration of diverse legal sources.

Box 4: Countries that liberalized or restricted their abortion laws between January 1998 and December 2007 [45]

Twenty countries have made substantial changes in their laws during these years; 16 countries added indications or recognized rape, incest or fetal impairment as grounds for legal abortion; and 2 countries added restrictions, as shown in the following table.

Expanded legal grounds

The Americas/Caribbean Colombia, Mexico DF, Saint Lucia

Central Asia/Middle East/ Iran

North Africa

East & South Asia/Pacific Australia (some jurisdictions), Bhutan, Nepal, Thailand

Europe Portugal, Switzerland

Sub-Saharan Africa Benin, Chad, Ethiopia, Guinea, Mali, Niger, Swaziland, Togo

Restricted existing grounds

The Americas /Caribbean El Salvador, Nicaragua

Other reforms

Ten other countries increased access by diverse strategies such as speeding up the approval of facilities (India) ; expanding the cadres of providers (Vietnam and South Africa ); expanding the range of methods available (Ethiopia) , re-interpreting the law to make more abortions legal (Thailand) , or removing restrictions on the ability of non-residents to obtain abortions (Denmark and Sweden).

Box 5: Examples of recent legal changes in expanding access to legal abortion in Africa

2004: In Ethiopia, the Parliament passed one of Africa’s most progressive abortion laws. A year later, the Ethiopian Ministry of Health released guidelines for safe abortion services, making major progress toward expanded abortion access in cases of rape, incest, and fetal impairment, as well as when a woman lacks the capacity to raise a child due to a physical or mental infirmity or her status as a minor. [46]

2010: In Kenya, a new Constitution was approved which provides that “A person shall not be denied emergency medical treatment.” It explicitly permits abortion when “in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the [pregnant woman] is in danger, or if permitted by any other written law.” [47]

Box 6: Examples of recent legal changes in expanding access to legal abortion in Latin America

2006: In Colombia, the Constitutional Court struck down as unconstitutional a total abortion ban, finding that it infringed a range of rights protected by Colombia’s constitution and international human rights treaties. It ruled that abortion must be permitted when a pregnancy threatens a woman’s life or her physical or mental health, and in cases of rape, incest, or grave fetal malformations incompatible with life outside the womb. The Colombian Constitutional Court´s decision was grounded in the right to dignity, the right to free development of the individual, and the rights to life, health, and bodily integrity. It also acknowledged that other fundamental rights, such as the right to work and the right to education are impacted by women’s ability to control their reproductive lives. The court further stated that “sexual and reproductive rights emerge from the recognition that equality in general, gender equality in particular, and the emancipation of women and girls are essential to society. Protecting sexual and reproductive rights is a direct path to promoting the dignity of all human beings, and a step forward in humanity’s advancement towards social justice.” [29]

2007: In Mexico City the Penal Code was amended to permit abortion on request in the first 12 weeks of pregnancy. This change followed major reforms over seven years which had expanded grounds for abortion, created procedures for obtaining abortion in cases of rape and involuntary insemination, and required the government to ensure that women could obtain abortions, free of charge, in public health facilities. Providers were granted a limited right to refuse to perform abortions on grounds of conscience, as long as a woman’s life or health was not in danger and the provider referred her to a doctor who was not a conscientious objector. In addition, a number of other Mexican states with restrictive abortion laws, including Chihuahua, Mexico State, Morelos, Baja California Sur and Hidalgo, added grounds in which abortion is permitted or not punishable, such as risk to a woman’s health and fetal impairment. [48]

Box 7: Examples of recent legal changes in expanding access to legal abortion in Asia

2002: In Nepal, prior to 2002, although the legal code provided that abortion was a crime “except while doing something for the purpose of welfare,” the law was interpreted as prohibiting abortion under all circumstances. Abortion law reform came as part of comprehensive legislation aimed at ending discrimination against women in the country’s legal code. Public awareness of high rates of maternal mortality, as well as the fact that women were being imprisoned for having illegal abortions, created pressure on the Parliament to liberalize the law. Under the amended legal code, abortion is now permitted at a woman’s request during the first 12 weeks of pregnancy, and thereafter in cases of rape or incest or fetal impairment, or if there is a threat to the woman’s life or physical or mental health. The amended legal code bans abortions performed for the purpose of sex selection. [11]

2005: In Iran a law was approved that allows abortions during the first 4 months of pregnancy in cases of fetal impairment and when disease endangers the life of the woman. This reform has been the first change since a new Penal Code, based on Islamic law, was enacted after the 1989 revolution. [42]

Box 8: Examples of recent legal changes in expanding access to legal abortion in Europe

2002: In Switzerland abortion was made legal without restriction as to reason during the first 12 weeks of pregnancy, and thereafter if the pregnancy is a threat to the woman’s life or physical or mental health. Previously, the law permitted abortion only on broad health grounds. [156]

2007: In Portugal abortion was made legal on request until the 10th week of pregnancy and thereafter in cases of fetal impairment, when the pregnancy results from a crime against sexual freedom or self-determination, or when the pregnancy is a threat to the woman’s life or physical or mental health. Previously, the law had permitted abortion only when a woman’s life and physical or mental health were in danger and in cases of rape or fetal impairment. [156]

On balance, there is a noticeable trend towards liberalization of abortion laws worldwide. Particularly over the last 10 years, as Boland and Katzive and other specialists in the field have noted, there is a trend towards using human rights principles to support women´s right to safe abortion. [42]

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5. Medical abortion is a critical means to expand access to safe abortion

Box 9: What is medical abortion?

Medical abortion is the termination of pregnancy through the use of misoprostol or a combination of mifepristone and misoprostol. It has revolutionized the experience of abortion, because it does not require surgical intervention. Medical abortion means that women can now have a choice of abortion method, including in the absence of health service facilities providing safe abortions. It also has the potential to expand access to abortion provided by clinicians and mid-level providers who may or may not have training in aspiration or surgical methods of abortion. It enables women in early pregnancy to use the pills and have their abortion at home if they prefer to do so, as long as they have access to appropriate back-up medical services if required.

For more detailed clinical information (safety and efficacy, dosage and regimens) of medical abortion, go to https://medicalabortionconsortium.com/articles/for-health-care-providers/health/?bl=en

Medical abortion has contributed to the reduction of complications of unsafe abortion and related mortality in legally restricted settings.

Given the urgent need to contribute to reducte deaths and morbidity from unsafe abortion, medical abortion has an important role to play in the expansion of access to safe abortion. Moreover, abortion is legal for some indications in practically all countries of the world, making safe abortion available relevant everywhere, including in legally restrictive settings, where women are increasingly self-medicating using medical abortion pills despite a wide range of barriers. [49], [50]

In countries where abortion is legally restricted, the use of medical abortion by women through self-administration or on the advice of a health professional (including a mid-level provider) is safer than other traditionally used methods, particularly unsafe invasive methods or hazardous substances. Indeed, in the few places where data have been recorded, including Brazil, the widespread use of misoprostol has led to a large fall in the numbers and seriousness of complications (see Box 10). [51]

Box 10: Impact of the utilization of misoprostol on unsafe abortion [52]

Sales of misoprostol, number of abortion complications treated in hospitals and abortion-related deaths, Gôiania, Brasil, 1987–91.

Medical abortion is recommended by international medical and scientific bodies

2001: the International Federation of Gynecology & Obstetrics (FIGO) issued a “Consensus Statement on Uterine Evacuation” that recommended: "Vacuum aspiration and medications for uterine evacuation should be introduced instead of sharp curettage to improve the safety and quality of abortion services for women”. [53] The safety and acceptability of medical abortion were already well documented. [54], [55] Misoprostol was found to be as effective as vacuum aspiration in the management of incomplete abortion, [56] even though complete abortion rates are generally lower in women who use medication for induced abortion or treatment of missed abortion, compared to aspiration abortion. [57]
2003: WHO recommended medical abortion in its technical and policy guidance on safe abortion, based on almost two decades of international research on its safety and efficacy. [58]
2005: WHO added medical abortion (mifepristone plus misoprostol) to its Model List of Essential Medicines. [59] This list includes the most efficacious, safe and cost-effective medicines for priority health conditions and are selected on the basis of current and future public health relevance, and their potential for safe and cost-effective treatment.
2011: WHO included both mifepristone plus misoprostol in the List of Essential Medicines for Mothers and Children and made recommendations to governments to make them available for the improvement of maternal health. [60]

Medical abortion is acceptable to women

Unintended pregnancies are a fact of life. Even in societies where contraceptive use is very high, women (and their partners) may end up with an unintended or an unwanted pregnancy for many reasons, ranging from sexual abuse or coercion to contraceptive failure or failure to use contraception. Among over 700 million women using a contraceptive method, 33 million (or 5%) are likely to experience an accidental pregnancy. [2] Some pregnancies that are wanted may become unwanted due to a diagnosis of serious fetal impairment or the woman’s life or health may become at risk during or due to the pregnancy. Lastly, pregnancy tests can now identify a pregnancy even before a woman misses her period. Where medical abortion is accessible, this means that the pregnancy can be terminated very early and effectively if it is unwanted.

Box 11: Evidence shows that many women prefer medical abortion [61], [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72], [73], [74]

women feel it is more natural
it does not involve surgery or anaesthesia
it can be used as soon as a woman learns that she is pregnant
women feel more in control of the process because it happens in their bodies
they perceive it to be consistent with the body´s natural processes
the great majority who have used medical abortion have said they would use it again if needed or recommend it to a friend.

As has been shown with contraception, choice of abortion method is an important feature of quality of care. Medical abortion provides women with the option of an early abortion that is safe, more easily accessible and less medicalized, while surgical abortion with manual or electric vacuum aspiration offers a procedure that takes only a short time and is carried out by a provider. Offering a choice between medical and surgical abortion allows women to choose the method that is more suited to them and upholds women’s right to benefit from technological and scientific advances.

When countries fail to provide safe abortion services, medical abortion is being used by women by themselves. Abortion with pills is far safer than the unsafe surgical or traditional abortion methods that women had to use in the past when desperately trying to end an unwanted pregnancy, and it is very similar to a spontaneous miscarriage. Follow-up treatment for miscarriage and even post-abortion care is available and not against the law anywhere, although good standards of care are not always guaranteed and post-abortion contraception is not always available.

Given these conditions, in recent years the expansion of access to and use of medical abortion all over the world has increased considerably. Different strategies such as information and referral hotlines, internet purchase, distance counselling by email, pre-and post-abortion counselling for providing information and counselling to women in need of an abortion have been increasingly used – mainly by civil society organizations, health services, and women´s groups to improve access to safe abortion, particularly in legal restrictive settings. [75], [76] This shows how much women are accepting medical abortion drugs when they need an abortion.

Medical abortion is effective and should be available at a low cost

It is safe and effective for delivering both abortion and post‐abortion care services, and for both first and second trimester abortions as well as early abortions. [51], [77], [78], [79], [80]
It is as safe as vacuum aspiration abortion. The risk of developing a complication is very low: less than 1% of women have developed infection after medical abortion in the first nine weeks of pregnancy, and no more than one in 1,000 women experiences heavy bleeding requiring a blood transfusion. [81], [82] Moreover deaths following medical abortion are very, very rare.
It is cost‐effective because services can be provided by a range of mid-level health professionals and requires less infrastructure to be delivered. Given that mid-level providers often work in rural or remote areas where physicians are scarce and where there are few surgical facilities or equipment, the expansion of medical abortion provision has the potential to greatly improve the reproductive health of women worldwide. [83] In France, Great Britain, Switzerland, Germany, Sweden, Viet Nam, South Africa and a growing number of states of the United States, nurses and midwives are permitted to provide medical abortion under the supervision of a physician. [84], [85], [86], [87]
It offers a choice both for women and providers, and can put the means of abortion into women’s hands, preserving their privacy and confidentiality.
It requires only a modest initial investment in facilities and training of appropriate providers. Medical abortion within 9 weeks of pregnancy can be provided in primary care settings, including in low-resource settings. [88] There are few complications and most do not require emergency referral. [62], [89]
It is also useful for second trimester abortion. [90] These abortions account for approximately 10–15% of all termination procedures in countries where abortion is legal, [91], [92] although in others, such as India and South Africa, the proportion has been reported to be as high as 25%-30%. [93], [94], [95]

Box 12: The safety and cost-effectiveness of medical abortion have encouraged health providers in many countries to be positive about its introduction

In Nepal, providers have generally been positive about the potential for introducing mifepristone and misoprostol, and pharmacists willing to stock the medicines. [96]

In South Africa, both policy-makers and service providers were generally favourable towards medical abortion, explaining that it could provide an additional method and might reduce the burden on health service personnel as well as being easier from a conscience point of view. [84]

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6. Who supports safe, legal abortion, including medical abortion?

Advocacy for increased access to safe legal abortion has increased worldwide. These efforts are rooted in public health, human rights, and other arguments. Those involved include health and medical professionals, women’s groups, feminist movement, legal and human rights advocates, young people, government officials, and, in some countries, trade unionists. [97]

Women´s health and rights movements

Advocating for safe, legal abortion has been carried out by women´s groups for more than 100 years. In many countries worldwide, calls for law reform and social debate, as well as policy development and monitoring of service delivery have been part of the political agenda of women´s health and rights movements. Experience shows that despite regional and national differences, their strategies have been similar everywhere. These have varied from lobbying parliamentarians, demonstrations and street actions, dissemination of information to women, building alliances with key stakeholders (particularly policymakers, health professionals and legal experts), sensitizing the medical community and journalists, conducting research for evidence both about public health aspects of safe and unsafe abortion and women's experiences, developing public campaigns, monitoring health policies, holding governments accountable for commitments they have made, and taking cases to court both as regards the law on abortion and in defence of individual women and abortion providers.

All these strategies have been based on the same principles, [11] which have been spelled out most recently by the International Campaign for Women's Right to Safe Abortion: [98]

Women have the right to make their own decisions whether and when to have children and have access to the means of acting on those decisions without risk to their health and lives.
Access to safe abortion is a woman´s right based on the principles of the right to life, the highest attainable standard of health, bodily integrity, the benefits of scientific progress, and to information, privacy, freedom from cruel, inhuman or degrading treatment or punishment, and equality and non-discrimination. The failure to give women access to safe abortion puts these rights at risk.
Restrictive laws do not reduce the number of abortions and they have serious public health, social and economic consequences.
Policies and practices that impede access to safe abortion where legal terminations should be available must be eliminated.
All barriers to women’s access to safe abortion should be removed. Women should be afforded universal access to abortion, delivered according to the most up-to-date WHO guidance. Access to safe abortion is a matter of equity and should never be compromised. Abortion should be an integral part of women’s health services, and should be provided as early as possible and as late as necessary.

In every region of the world, women´s health and rights groups and movements have succeeded in moving forward a women´s rights agenda and in creating enabling conditions in the cultural, social and political realms of their countries to make the needed changes in abortion law and make safe abortion service provision not only possible but also sustainable. [99], [100], [101], [102], [103], [104]

Health professionals

Health professionals have also played a pivotal role in many parts of the world. They are at the front lines where abortion is unsafe, because they are the ones who have to deal with the sometimes horrific damage to women's bodies that dangerous abortions cause, and watch women die when they are unable to save them. They have taken personal risks to provide abortions clandestinely because of their oath to do no harm, and their commitment to promote and protect health and to save lives. They have formed their own campaigning groups for safe abortion as health professionals, and they have participated in campaigns organised by others. They have also in recent decades promoted the registration of abortion medications and access to medical abortion as a safe and cost-effective method for pregnancy termination where governments have been slow to register this method. They have played a leading role as educators, witnesses, providers and persuader, [105] in social and legislative debates, and in the design and implementation of public policies to make safe abortion accessible. [106], [107]

Health professionals and their associations have had an important task at international, regional and national levels not only to sensitize their own community, but also to document the impact of unsafe abortion through research as an essential part of their professional practice.

Box 13: Safe abortion initiatives by physicians

1. International Federation of Gynecology & Obstetrics (FIGO)

In 1998, FIGO disseminated guidelines entitled “Ethical Aspects of Induced Abortion for Non-Medical Reasons” as part of a set of recommendations available from their Committee for the Ethical Aspects of Human Reproduction and Women’s Health. These recommendations included the following statement: “Providing the process of properly informed consent has been carried out, a woman’s right to autonomy, combined with the need to prevent unsafe abortion justifies the provision of safe abortion.” [108]

In 2001, FIGO issued a “Consensus Statement on Uterine Evacuation” that recommended "Vacuum aspiration and medications for uterine evacuation should be introduced instead of sharp curettage (also known as dilatation and curettage or D&C) to improve the safety and quality of abortion services for women." [53] They recognized that the safety and acceptability of medical regimens for uterine evacuation were well documented, [51], [55] that misoprostol is as effective as vacuum aspiration in the management of incomplete abortion, [56] and that the complete abortion rates are generally lower in women who use medication compared to aspiration for the treatment of missed and induced abortion. [109]

In 2007, FIGO launched the Prevention of Unsafe Abortion Initiative, which aimed to carry out a situational analysis of induced and unsafe abortion in a number of countries, followed by the preparation of national plans of action for addressing and overcoming the problems identified, and the implementation of those plans of action. By the end of December 2009, analyses had been carried out in over 50 countries and national plans of action had been produced in 43 countries, with the overall aim of the prevention of unsafe abortion. Of these, 27 of the countries made their reports publicly available, at: http://www.figo.org/news/figo-initiative-prevention-unsafe-abortion. The Initiative is now working for the implementation of those plans of action in collaboration with national governments and stakeholders, and they hold meetings in each of these regions, attended by a range of stakeholders. [110]

In 2009, a number of ethical guidelines by the FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health, were published in collected form in a booklet entitled "Recommendations on Ethical Issues in Obstetrics and Gynecology", by the FIGO Committee for the Study of Ethical Aspects of Human Reproduction. These include guidance on the ethical obligation of health professionals to disclose a conscientious objection to abortion, and to make an appropriate referral so that the woman can obtain the full information necessary to decide whether to terminate a pregnancy. [111]

2. Global Doctors for Choice [112]

This network was formed in 2007 by two US physicians and is now led by an international steering committee. They have held meetings in multiple cities, fostering collaboration among physicians from Brazil, Chad, Colombia, Ghana, Ireland, Mexico, Portugal, South Africa, the United States, Uruguay, and other countries. They have conducted advocacy trainings for doctors in Cape Town, Mexico City, and Bogota, and several of their members have formed vital relationships with NGOs, government officials, and transnational advocates. In connection to events in Brazil, Nicaragua, Poland, and the United States, the network has issued amicus briefs and public statements to support physicians’ care for patients’ reproductive health needs. In October 2010, they convened a meeting on how to develop a global response to conscientious refusal of care restrictions.

3. National groups and associations

Many other initiatives in the form of global, regional or national networks have been launched over the years to bring together health professionals working to make social and political change possible in order to improve access to safe abortion. Physicians for Reproductive Choice and Health (PRCH), [109] Medical Students for Choice in the USA [113] and Doctors for a Woman’s Choice on Abortion in the UK [114] are only three examples of national initiatives by health care providers and medical students to work for expanded access to abortion through legal changes and advocacy within and beyond the profession.

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7. How policy makers can support safe legal abortion

Policy makers can and do play a key role in ensuring that safe abortion is accessible to every woman who seeks an abortion in their countries. Policy makers in a growing number of countries are realising thanks to the Millennium Development Goals that access to safe abortion is an essential way to reduce maternal mortality and morbidity and support women's right to decide the number and spacing of their children.

What can policymakers do?

Where abortion is legal on a broad range of grounds

Promote government approval of medical abortion drugs (mifepristone and misoprostol) as essential medicines through the national national drug regulatory agency and ensure that regulations allow them to be made available in the health system, including at primary care level

Medical abortion with mifepristone+misoprostol represents decades of medical research to develop a safe alternative to surgical abortion, and misoprostol alone has proven valuable for other obstetric uses. (https://medicalabortionconsortium.com/articles/for-health-care-providers/health/?bl=en)
National essential medicine lists serve as the most important basis for public sector drug procurement and distribution, and the inclusion of mifepristone and misoprostol in these lists should be a priority. Policy makers can also ensure that pharmaceutical companies make mifepristone and misoprostol available in the country, ensuring their quality and affordable prices.

Develop guidelines for the best use of medical abortion in the health system

Evidence-based guidelines assist health care providers in their clinical decisions and also benefit women. They should be in line with the WHO's updated guidance, and include the use of medical abortion for both first and second trimester abortions, and details of WHO-recommended dosage and regimens for medical abortion. (https://medicalabortionconsortium.com/articles/for-health-care-providers/health/?bl=en)
Guidelines need strategic dissemination in order to be widely used. The knowledge transfer strategy should guarantee that all those in charge of health care provision –mainly gynaecologists, mid-level providers and pharmacists – are well informed about the most up-to-date evidence.

Box 14: Introducing medical abortion into health services

Mongolia, 2003: Abortion was made legal on request in Mongolia in 1989. Concerned about the high number of abortions and inadequate quality of care in abortion services, the Ministry of Health invited WHO to do a strategic assessment of abortion and contraception services, to develop policies and programmes to reduce unintended pregnancies, mitigate complications from unsafe abortion, and improve the quality of abortion and contraception services. National standards and guidelines for comprehensive abortion care were developed that included the introduction of mifepristone and misoprostol. The national training curriculum was harmonized with the new guidelines. One third of the country's gynaecologists were trained in manual vacuum aspiration and medical abortion, and three model comprehensive abortion care units were established, to provide high quality services to women, high quality training for providers, and to support further scaling up. [115]

Moldova, 2005: The WHO Abortion Needs Assessment led to new national abortion standards and guidelines, a national provider training curriculum and information, education and communication materials for women, which were approved by the Ministry of Health. In addition, a demonstration project implementing comprehensive abortion care in two centres was evaluated and the scaling up of activities to additional centres was fostered. [116]

Mexico City, 2007: After legalization of abortion in 2007, the Secretariat of Health of Mexico City (SSDF) equipped affiliated clinical providers with the evidence base for how to provide safe, effective abortion services, which included a medical abortion protocol in the procedures manual. The programme had the support and guidance of the heads of the legal pregnancy termination programme in Mexico City, and the assistance of Gynuity Health Projects. [117]

Bring together abortion providers and health service managers to assess the best way to include medical abortion in existing abortion services

Abortion need assessments conducted in several countries in different regions have shown success in a consensus-building process for introducing medical abortion in health systems and policies. Protocols for primary health care services have been developed with updated information about regimes and norms, referral procedures, ambulatory treatment and also home use of the medicines, thus making abortion more accessible for women.

Replace physician-only policies with those that enable mid-level providers to provide MVA and medical abortion pills in primary care settings, and invest in training

Physician-only regulations made sense when abortion methods were more invasive and had a greater risk of complications than procedures recommended by WHO today. Today, these regulations are outdated. There are a limited number of obstetrician-gynaecologists in most countries, and allowing mid-level providers to provide MVA and early medical abortion would significantly increase access to safe abortion for women. [118]
Mid-level providers include general practitioners, nurse-midwives, family planning nurses and other nurse practitioners. Evidence from both developed and developing countries shows that when appropriately trained, they can offer these services to women as safely as physicians. [119], [120]
Medical abortion training (both pre-service and in-service) can be offered to providers already trained in vacuum aspiration abortion and can also be organized for those not skilled at vacuum aspiration abortion. [121] Training should cover not only technical skills (including pain management), but also communication skills, ethical aspects, counselling and post-abortion contraceptive provision.

Ensure access to safe second trimester abortion as well

Although the great majority of abortions take place in the first trimester, a significant number are carried out in the second trimester. Studies have shown that women seeking a late termination do not recognize the signs of pregnancy, or found the decision difficult to take, or faced multiple delays in the health care system, among other obstacles. [122]

It is estimated that 10–15% of all abortions globally take place in the second trimester, over half of which are considered unsafe. Restrictions on access to second trimester abortions may push women to seek an abortion under unsafe conditions, thus increasing the risk of morbidity and mortality.
Unsafe second trimester abortions account for two-thirds of all admissions to hospitals due to complications and contribute disproportionately to unsafe abortion deaths. [6] Yet the law in many countries is equivocal or unclear on this subject. It is therefore crucial to reform the law in many cases to make second trimester abortions legal and ensure physicians are using WHO-approved methods (medical abortion or dilatation & evacuation), in order to reduce this serious public health problem. [123], [124], [90]
Many countries where abortion is broadly available in the first 10-18 weeks place upper time limits on when abortion may be obtained. Abortion at a woman’s request is usually permitted up to 12–14 weeks of pregnancy, or as in Sweden up to 18 weeks. After this, abortion may be permitted only on grounds of risk to the woman’s life or health, or in cases of rape or fetal impairment. In some countries, the permission of one or more medical practitioners or a medical board may be required. Although these restrictions may have been intended to avoid the morbidity and mortality associated with later abortions, these procedures are now also very safe where legal and available.

Policy makers should be concerned about how norms can be changed in order to better respond to the needs of this group of women, many of whom are young and/or vulnerable, as well as to reduce delays and barriers to accessing abortions as early as possible. Laws should be reformulated to be clear and precise.[125], [126]

Where abortion is legally restricted

Use the WHO strategic approach to study the situation of abortion in your country

For example, the WHO Department of Reproductive Health and Research carries out national strategic assessments with the aim of strengthening sexual and reproductive health policies and programmes [125] in a growing number of countries, by invitation of the country Ministry of Health to do so. Participants in the assessment always include government representatives and other policymakers, health systems representatives, health professionals working in abortion and reproductive health, and representatives of NGOs and other relevant civil society groups. A number of assessments have been undertaken on the prevention of unsafe abortion and how to increase access to comprehensive abortion care, including in Viet Nam, Cambodia, India, Romania, Moldova, Guinea, Malawi and the Russian Federation. [126], [127], [128], [36], [129]

Policy makers have been key participants in all these WHO assessments. Given the positive impact that these strategic assessments have had, policy makers in countries where abortion is legally restricted could encourage their Ministries of Health to invite WHO to carry out such an assessment [130] and then work with others inside the country to share its findings and implement its recommendations.

Ensure that abortion services are accessible to women who are legally eligible for an abortion

In settings where abortion is legal only on specific grounds (e.g. risk to life and health, rape, incest, fetal impairment), policy makers give unequivocal political support for the provision of safe and legal abortions under their current laws and guarantee that women who meet these grounds have access to safe abortions.
Often, health care providers feel unable to provide abortions that are legally permitted because they think they are not authorised to do so, or they believe judicial authorisation is required when it is not. [131], [132], [133] Sometimes, third parties (often conservative political and religious groups) try to take legal action to prevent the provision of these abortions despite their legality. Policy makers need to ensure that legal services are in place and develop mechanisms that confirm health providers' right to carry out legal abortions and, indeed, inform them of their responsibility to do so.

Box 15: National policy developments

Brazil: Abortion is legal in Brazil if it is the only means to save the woman's life or if the pregnancy is the result of rape. Although this has been the law for over 60 years, it has almost never been applied until recent years. In 1998 a sensitization and advocacy project was launched by the national ObGyn society (FEBRASGO) to motivate key individuals within the health system and hospital staff to provide services for pregnancy termination in cases of rape. The support of medical professionals and the women's health and rights movement, together with political support at federal, state and city levels, including from the Federal Ministry of Health, were important elements in improving access to legal abortions. As a result of this experience, local and state governments have been working with hospitals to provide integrated services for women who have been raped, including counselling and support, treatment for sexually transmitted infection, emergency contraception and abortion if required. [134] In 2005, the Federal Ministry of Health issued guidance on providing abortion services in cases permitted by the law. [135]

Box 16: The "health exception" strategy in Latin America [136]

Risk to the woman's health is one of the legal grounds for the termination of pregnancy allowed by the majority of Latin American and Caribbean countries, as well as countries in other world regions. This is called the "health exception" (causal salud) in Latin America. However, its practical application has been limited by a wide range of barriers. Recent significant legal rulings have made an important contribution to the interpretation and application of this exception in permitting abortions, along with a number of international interpretations of the right to health that interpret the concept of health in a broad and integrated manner.

In 2007, an initiative called “Causal Salud” was launched in Latin America, aimed at elaborating an interpretation of the health exception from a human rights perspective, based on the WHO comprehensive definition of health and taking into account the resolutions and recommendations of international human rights bodies. The initiative brought together a network of institutions and professionals from diverse backgrounds in the sexual and reproductive health and human rights fields, and used a web platform for discussion of the text. The result of this consensus-building process was published in 2009. It has been widely used in the region as a tool for advocacy and for sensitizing health providers, policy makers and legislators in order to expand access to abortions on health grounds as permitted by existing laws.

Ensure that both medical and aspiration abortion methods are available for legal abortions and for post-abortion care to treat complications from unsafe abortions

Misoprostol is available in a growing number of countries for indications apart from abortion, e.g. in almost all Latin American and Asian countries and increasingly in Africa. This can pave the way for its approval for prevention of post-partum haemorrhage (recently supported by WHO, with new guidance expected in the second half of 2012), [137] post-abortion care, and abortions that are permitted by law.
Medical abortion is a non-invasive means for providing post-abortion care services. It is effective for both first and second trimester abortions, as well as early abortions. [77], [78], [79]

Remove barriers that make it impossible for women to access a legal abortion in a timely manner

Barriers to accessing legal abortion services exist even in countries where abortion is permitted for a broad range of indications, as well as in countries with more legal restrictions. [138], [139] These barriers cause delays, meaning that women have abortions later than they otherwise could have done. As a way to avoid these barriers, women may seek an unsafe abortion, especially if they cannot afford fees for private services, with all the risks to health and life that this may bring about. It is therefore important to remove these barriers, which may require changes in abortion regulations.

Box 17: Common barriers to accessing legal abortion [140]

Mandatory counselling

Counselling regarding women's decision whether to have an abortion should never be mandatory but available if women ask for it. Provision of information, on the other hand, about abortion methods, the abortion process, and about post-abortion care, along with the provision of information about contraception are key components of a comprehensive safe abortion service.

Most women have already taken the decision to terminate their pregnancy when they reach a health facility seeking an abortion. However, if a woman looks ambivalent or uncertain on what to do, or seems to be under pressure from her partner or members of her family, she should be given non-directive counselling in order to help her take a decision by herself.

Mandatory waiting period

Once a woman has requested an abortion, it should be take place without delay. Mandatory waiting periods are not part of good medical practice. There will always be a few women who change their minds and cancel, a mandatory waiting period is unnecessary.

Consent of a third party, e.g. spouse or parent

Several countries require a married woman seeking abortion to obtain the consent of her spouse. While women often involve their partners in the decision, the involvement of the partner should be at the woman’s discretion. In some countries, girls under a certain age are asked to obtain the consent from parents or a guardian, or a court authorisation. Girls who are having a sexual relationship should be considered mature enough to take their own decision.

Abuse of the exercise of conscientious objection

Some providers do have a legitimate conscientious objection to providing abortions. Others, however, may use conscientious objection as an excuse not to provide abortions in the public health system while offering women their services privately. The latter is an abuse of women’s right to health care, as discussed in the FIGO Ethical Guidelines on Conscientious Objection. [141] Moreover, conscientious objection applies only to individuals, not to health institutions. It is a violation of medical ethics for a clinic or hospital to refuse to perform legal abortions on this basis.

Introduce the harm reduction model in legally restricted settings

The harm reduction model, developed in Uruguay, consists of a pre- and a post-abortion consultation in setting where there are no legal public abortion services. In the pre-abortion consultation, a woman with an unwanted pregnancy is offered a medical examination to confirm pregnancy and gestational age and checked for any health problems and ectopic pregnancy. Information on the Penal Code and whether she is lawfully entitled to a pregnancy termination under its provisions is also provided. Evidence-based information on the risks of different methods of clandestine abortion, including the possibility of self-medication with misoprostol, is provided as well. This information includes the legal status of the medicine, the best dose and routes of administration, symptoms, side effects, mechanism of action, effectiveness, and problems of use at later gestational ages. No information is provided on where or how to obtain misoprostol, nor is the drug prescribed by the attending physician. Lastly, information is given about available social support should the woman continue the pregnancy or resort to adoption as an alternative. If the woman decides to terminate her pregnancy, she is encouraged to return for follow-up care. In the post-abortion consultation she is examined to confirm termination is complete and given care for any complications or incomplete abortion, if required. Information about contraceptive methods and services are also provided. Patient–provider confidentiality is protected and assured to women in both consultations. [142], [143], [144]

Box 18: Evidence of the public health value of the harm reduction model [145], [146]

This model was first piloted in the Pereira Rossell Hospital, in Montevideo, the main public maternity hospital in Uruguay by a group of obstetrician-gynaecologists who founded an NGO called “Iniciativas Sanitarias”.

From March 2004 through June 2005, 675 women attended the pre-abortion consultation and 495 the post-abortion visit, with the number increasing over time. Some women (3.5%) decided not to abort, others were either not pregnant, or the fetus/embryo was dead or the woman had a condition that permitted legal termination of pregnancy in the hospital (7.5%). The rest, however, all self-medicated with vaginal misoprostol, using the recommended doses. There were no serious complications (one mild infection and two with haemorrhage not requiring transfusion). [147] The number of women dying or suffering severe complications of unsafe abortion fell to zero.

Because of these results, in 2004, the Health Ministry enacted a regulation to implement this model in all public sector facilities and established guidelines for pre- and post-consultation. This regulation was subsequently affirmed in law. Thus, this service began to be provided with the full sanction of the State.

As some of the leaders of this initiative said: “This strategy of risk reduction within the climate of restrictive laws is an intermediate step on the road to approval of a law of sexual and reproductive rights.” [149] And in 2011 and 2012 the two houses of the parliament of Uruguay passed an abortion law reform bill.

Support reform of restrictive abortion laws and policies to make abortion safe, legal, accessible and affordable

On both public health and women's rights grounds, policy makers should promote abortion law reform as part of a comprehensive strategy to reduce the negative impact of unsafe abortion and the positive impact that access to safe abortion has in reducing maternal mortality and morbidity.
Making abortion legal is a prerequisite to making it safe. Safety is achieved not only by supplying safe abortion services but also by removing the stigma of illegality, the fear of exposure and imprisonment, losing the right to practice medicine and other punitive measures against both women and providers. Safety is also ensured by making clandestine and unskilled providers redundant.
Good laws and policies on abortion are also a sign of public acceptance of women´s need for abortion and the legitimacy of abortion as an essential part of women's health care. Just as importantly, they indicate public awareness of the costs of unsafe abortions, not only to women but also to their existing children, partners and families, and to health services and society as a whole. [135]

In all countries

Promote the use of up-to-date, comprehensive guidelines and training resources

Nationally appropriate service delivery standards, protocols and guidelines should be developed where these do not already exist, and must be regularly updated. WHO’s comprehensive guidance, released in June 2012, is an excellent document for doing so. The following are considered the best existing evidence-based guidelines available:

- WHO – Safe Abortion: Technical and Policy Guidance for Health Systems, 2012. [40]

- UK Royal College of Obstetricians and Gynaecologists – The Care of Women Requesting Induced Abortion, 2011. [148]

- Gynuity Health Projects – Providing Medical Abortion in Low-Resource Settings: An Introductory Guidebook, 2009. [149]

- American College of Obstetricians and Gynecologists – Misoprostol for postabortion care, 2009. [150]

- Ipas – Medical Abortion Training Resources, 2010. [151]

Quality of care not only entails technical skills and quality medicines but also the promotion of women’s autonomy in making the abortion decision and providing abortion services in a manner that respects women’s dignity, confidentiality, privacy and choice of method, and the provision of accurate information and good quality counselling if requested.

Promote documentation of abortion statistics and service delivery

Operational research and monitoring is needed in order to ensure quality of care from the perspective of providers and women. Documentation of the logistical, administrative and organisational challenges faced in the introduction of recommended methods of abortion in place of out-of-date methods such as D&C and in the scaling up of reproductive health services is needed for those working at the policy and programme level. Documentation of data on abortions, e.g. numbers of women, length of pregnancy, abortion method used is critical to inform budget planning, adequacy of services and training needs.

Support public health funding to make abortion services, including medical abortion, affordable for all women.

The cost of abortion for women and for health systems is a critical issue for policy makers.
While misoprostol is available in almost all countries (except a few sub-Saharan African and Asian countries), mifepristone is much less available. [152] However, misoprostol is often registered for the treatment of gastric ulcers and not for termination of pregnancy or post-abortion care. [153], [152] More recently, it has also been registered in some countries for the prevention of post‐partum haemorrhage and labour induction. Indeed, in many countries, it is being used alone for medical abortion because of the low cost and also because mifepristone has not been registered for abortion.
More than 60 manufacturers are producing both drugs worldwide and a rapid proliferation in products has taken place in the recent years. Prices of mifepristone and misoprostol differ considerably between countries, and in countries where misoprostol is used outside the law, its price can be very high. [154], [155]
In some countries, the availability of medical abortion drugs is hindered by expensive, rigorous and time-consuming regulatory approval processes. Policy makers can seek to simplify the approval process and work for the availability of generic misoprostol and mifepristone which will facilitate the ability to obtain these essential medicines at low prices.
Health insurance, especially for low-income groups, should provide coverage for abortion services, including medical abortion. In the absence of such schemes, public policies should guarantee low or no fees for abortion in order to make access to safe abortion affordable for all women.

Key points for policy makers

Support law reform to allow more grounds for abortion in order to better respond to women's needs and rights.
Guarantee access to all abortions permitted by the law.
Ensure the development and use of up-to-date and comprehensive guidelines for MVA and medical abortion provision.
Ensure that abortion providers, including mid-level providers, are trained in and using MA and MVA, and stop using D&C.
Ensure that health systems offer abortion services, especially at primary level for first trimester abortions, and at community or district hospitals for second trimester abortions
Guarantee that generic, high quality medical abortion drugs are approved, and available at reasonable prices, and that MVA and EVA equipment is available.
Ensure that post-abortion care is provided and that post-abortion contraception information and services are offered.
Ensure that conscientious objection is not abused and that objectors are required to refer women to suitable services.
Include abortion care at low cost or free in public health insurance schemes, protecting access for women with little or no income.
In sum, support women’s autonomy to make their own decisions whether and when to have children and have access to the means of acting on those decisions without risk to their health and lives. [98]

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8. References

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Ipas. Ensuring women’s access to safe abortion: Essential strategies for achieving the Millennium Development Goals. Chapel Hill, Ipas, 2005.
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Centre for Reproductive Rights. Safe and legal abortion is a woman’s human right. Briefing paper. New York, Centre for Reproductive Rights, August 2004.
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