The ICMA Information Package on Medical Abortion
Information for policymakers / Updated in 2013
The International Consortium for Medical Abortion (ICMA) works to promote medical abortion within the framework of support for safe abortion worldwide, focusing on the needs of women in developing countries and countries where abortion is unsafe or not accessible.
This section is part of a comprehensive information package with four sections, each aimed at a specific audience: women seeking information about abortion (https://medicalabortionconsortium.com/articles/for-women/main-book/?bl=en); women’s health advocates, abortion rights organizations, and other NGOs that support women’s reproductive rights (https://medicalabortionconsortium.com/articles/for-women-advocates-ngos/book3/?bl=en) ; health care providers (https://medicalabortionconsortium.com/articles/for-health-care-providers/health/?bl=en); and policy makers.
This section is for policy makers who want to know about how to address the topic of unsafe abortion effectively, improve laws, policies and regulatory frameworks to ensure abortion is safe, and include medical abortion (MA) provision in the health care system.
|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.” 
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.  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. 
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.  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”.  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. 
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,  and the proportion of all abortions that were unsafe increased from 44% to 47%. ,  The 2011 WHO report  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). 
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.
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. , 
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. 
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.  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. , 
|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. 
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. 
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. 
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.  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. 
Moreover, an estimated 220,000 children worldwide lose their mothers every year due to abortion-related deaths;  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.  , 
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.  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.
Most post-abortion care is provided by public health facilities.  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.  This is in addition to the estimated US$490 million spent annually in Africa and Latin America on treating obstetric emergencies. 
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. , 
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. 
Legal prohibition does not deter women from having an abortion, as a 2012 study by the Guttmacher Institute showed.  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.  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. 
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. 
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. 
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.  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). 
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. 
|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.  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.
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. 
|5. Medical abortion is a critical means to expand access to safe abortion|
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. , 
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). 
Medical abortion is recommended by international medical and scientific bodies
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.  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.
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. ,  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
|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. 
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.
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. , , , , , 
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,  in social and legislative debates, and in the design and implementation of public policies to make safe abortion accessible. , 
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.
|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
Bring together abortion providers and health service managers to assess the best way to include medical abortion in existing abortion services
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
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. 
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., 
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  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. , , , , 
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  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
Ensure that both medical and aspiration abortion methods are available for legal abortions and for post-abortion care to treat complications from unsafe abortions
Remove barriers that make it impossible for women to access a legal abortion in a timely manner
Introduce the harm reduction model in legally restricted settings
Support reform of restrictive abortion laws and policies to make abortion safe, legal, accessible and affordable
In all countries
Promote the use of up-to-date, comprehensive guidelines and training resources
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.
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