Estimating abortion safety: advancements and challenges

In The Lancet, Bela Ganatra and colleagues1Ganatra B Gerdts C Rossier C et al.Global, regional, and subregional classification of abortions by safety: estimates for 2010–14.Lancet. 2017; (published online Sept 27.)http://dx.doi.org/10.1016/S0140-6736(17)31794-4Google Scholar present an innovative and important analysis of global abortion safety, in which they attempt to move beyond the binary understanding (safe or unsafe) of abortion safety. As the availability of misoprostol increases, and abortion telemedicine services reach more women worldwide, fewer women are undergoing abortions with invasive or outdated methods and more women are having abortions outside of formal health-care systems.2Gomperts RJ Jelinska K Davies S et al.Using telemedicine for termination of pregnancy with mifepristone and misoprostol in settings where there is no access to safe services.BJOG. 2008; 115: 1171-1175Google Scholar These changes prompt a need for rethinking how we view and measure abortion safety. Therefore, the study by Ganatra and colleagues is very timely. The approach used in the study, although it had limitations, offers a more nuanced gradation of safety: abortions were classified as safe or unsafe, and unsafe abortions were further divided into less-safe and least-safe categories. This three-tiered classification focused on two technical aspects of the abortion process (abortion provider and method) and is said by the authors to be aligned with the conceptual definition of unsafe abortion used by WHO. However, the safety classification did not consider abortion outcomes, as was recommended by Sedgh and colleages.3Sedgh G Filippi V Owoabi OO et al.Insights from an expert group meeting on the definition and measurement of unsafe abortion.Int J Gynaecol Obstet. 2016; 134: 104-166Google Scholar Outcomes were instead considered by examining the association between abortion safety and case fatality rates. An editorial4Ganatra B Tunçalp Ö Johnston HB Johnson Jr, BR Gülmezoglu AM Temmerman M From concept to measurement: operationalizing WHO's definition of unsafe abortion.Bull World Health Organ. 2014; 92: 155Google Scholar on how to operationalise and interpret the WHO definition of unsafe abortion states that, rather than a binary measure, abortion safety should be characterised along a risk continuum, which is affected by contextual factors, such as abortion laws and presence of stigma. The model and analysis used by Ganatra and colleagues did, to some extent, take the social and legal context into account. The authors divided factors affecting abortion safety into five conceptual domains: abortion service delivery environment; legal context of abortion; financial access to services; abortion stigma; and development. However, the model predictors used cannot be said to completely represent these domains because of the unavailability of predictor data. For example, although gender inequality might be the best available proxy for stigma, measures of gender inequality and data on the abortion process (provider type and abortion method) cannot capture all scenarios. Abortion stigma has a substantial impact on access to both safe abortion and post-abortion care. Young women who seek abortion (including from trained providers using evidence-based methods) sometimes turn to unsafe methods to manage bleeding and delay seeking care for complications because of costs and fear of stigma, exposure, and legal repercussions.5Cleeve A Faxelid E Nalwadda G et al.Abortion as agentive action: reproductive agency among young women seeking post-abortion care in Uganda.Cult Health Sex. 2017; 11: 1-15Google Scholar Not accounting for these types of outcomes results in an incomplete picture. Efforts are needed to measure and quantify abortion stigma to understand its implications for safety and quality of care. Another issue, recognised by the authors, is the poor association between drug registration and availability. Registration of mifepristone and misoprostol provides no assurance of the drugs being available or of high quality.6Cleeve A Oguttu M Ganatra B et al.Time to act—comprehensive abortion care in east Africa.Lancet Glob Health. 2016; 4: e601-e602Google Scholar The emergence of telemedicine services and mifepristone and misoprostol sold on the black market have further confounded the issue.7Iyengar K Iyengar SD Danielsson KG Can India transition from informal abortion provision to safe and formal services?.Lancet Glob Health. 2016; 4: e357-e358Google Scholar Additionally, information about availability of health-care providers who are willing and able to provide abortion care could be considered for future estimates because these providers are crucial for access to health care.8WHOHealth worker roles in providing safe abortion care and post-abortion contraception. World Health Organization, Geneva2015http://www.who.int/reproductivehealth/publications/unsafe_abortion/abortion-task-shifting/enGoogle Scholar, 9Arthur J Fiala C Gemzell Danielsson K et al.The dishonourable disobedience of not providing abortion.Eur J Contracept Reprod Health Care. 2017; 22: 81Google Scholar It is unclear whether the proportion of abortions estimated as safe by the authors (54·9%, 90% uncertainty interval 49·9–59·4) would remain the same if data on availability of mifepristone, misoprostol, and health-care providers; stigma; and abortion outcomes had been obtainable and taken into account. It is remarkable that, despite being preventable, 25·1 million unsafe abortions were estimated to have occurred annually between 2010 and 2014, 97% in low-income regions. Ganatra and colleagues emphasise the importance of liberal abortion laws, economic development, evidence-based medicine, and gender equality for abortion safety. Their findings raise the question of how WHO can work with member states to increase access to safe abortion care and to step up progress towards the Sustainable Development Goals (SDGs). The current SDG indicators do not include any specific measures of abortion access, safety, or quality of care,10Inter-Agency and Expert Group on Sustainable Development Goal IndicatorsRevised list of global Sustainable Development Goal indicators.https://unstats.un.org/sdgs/indicators/Official%20Revised%20List%20of%20global%20SDG%20indicators.pdfGoogle Scholar which we believe is detrimental to monitoring progress. It is time to implement evidence-based policies, programmes, and services that promote, protect, and fulfil the sexual and reproductive rights of all individuals worldwide. KG-D declares no competing interests. AC serves as a part-time consultant to the Department of Reproductive Health and Research at WHO, but was not involved in the study commented on here. Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical modelIncreased efforts are needed, especially in developing countries, to ensure access to safe abortion. The paucity of empirical data is a limitation of these findings. Improved in-country data for health services and innovative research to address these gaps are needed to improve future estimates.