BACKGROUND: Unsafe abortion remains a leading cause of maternal mortality and morbidity, especially in developing countries with restrictive abortion laws. Disease containment measures during the COVID-19 pandemic have reduced access to contraception and safe abortion care, potentially increasing rates of unintended pregnancies and unsafe abortion.
OBJECTIVE: To evaluate the morbidity and mortality burden of unsafe abortion before the COVID-19 pandemic.
METHODS: A six-year analytical retrospective study of unsafe abortion at the Federal Medical Centre, Lokoja, Nigeria. All case records of unsafe abortion managed within the study period were retrieved, and relevant data extracted using a purpose-designed proforma. Data obtained was analysed using the IBM SPSS Statistics for Windows, version 25 (IBM Corp., Armonk, N.Y., USA). Associations between categorical independent and outcome variables were assessed using the Chi square test at 95% confidence level. A p-value of <0.05 was considered statistically significant.
RESULTS: The prevalence of unsafe abortion was 8.6 per 1,000 deliveries. More than one-half (37, 52.9%) were medical abortions using misoprostol tablets. The mean age of the women was 23.15+ 3.96 years, and most of them were single (49, 70%), with primary/ secondary education (42, 60%), and of low socioeconomic status (67, 95.7%). Nearly one-half (33, 47.1%) had either never used any modern contraceptive (9, 12.9%) or only used emergency contraception (24, 34.3%). The predominant complications of unsafe abortion included retained product of conception (69, 98.6%), haemorrhagic shock (22,31.4%), and sepsis (19, 27.1%). There were two maternal deaths, giving a case fatality rate of 2.9%.
CONCLUSIONS: Unsafe abortion remains a significant cause of maternal mortality and morbidity in our setting. Improving access to effective modern contraceptives and liberalizing our abortion laws may reduce maternal morbidity and mortality from unsafe abortion.
BACKGROUND: L’avortement à risque reste l’une des principales causes de mortalité et de morbidité maternelles, en particulier dans les pays en développement où les lois sur l’avortement sont restrictives. Les mesures de confinement de la maladie pendant la pandémie de COVID-19 ont réduit l’accès à la contraception et aux soins d’avortement sûrs, augmentant potentiellement les taux de grossesses non désirées et d’avortements à risque.
OBJECTIVE: Évaluer le fardeau de morbidité et de mortalité de l’avortement à risque avant la pandémie de COVID-19.
METHODS: Une étude rétrospective analytique de six ans sur l’avortement à risque au Fédéral Médical Center, Lokoja, Nigeria. Tous les dossiers de tous les cas d’avortement à risque pris en charge au cours de la période d’étude ont été récupérés et les données pertinentes extraites à l’aide d’un formulaire conçu à cet effet. Les données obtenues ont été analysées à l’aide d’IBM SPSS Statistiques pour Windows, version 25 (IBM Corp., Armonk, N.Y., USA). Les associations entre les variables indépendantes catégorielles et les variables de résultat ont été évaluées à l’aide du test du chi carré à un niveau de confiance de 95 %. Une valeur de p <0,05 était considérée comme statistiquement significative.
RESULTS: L’prévalence des avortements à risque était de 8,6 pour 1000 accouchements. Plus de la moitié (37, 52,9%) étaient des avortements médicamenteux utilisant comprimés de misoprostol. L’âge moyen des femmes était de 23,15+ 3,96 ans, et la plupart d’entre elles étaient célibataires (49, 70%), avec une éducation primaire/secondaire (42, 60%) et de statut socio-économique bas (67, 95,7%). Près de la moitié (33, 47,1%) n’avaient jamais utilisé de contraceptif moderne (9,12,9%) ou n’avaient utilisé qu’une contraception d’urgence (24, 34,3%). Les complications prédominantes comprenaient la rétention du produit de conception (69, 98,6 %), le choc hémorragique (22, 31,4 %) et la septicémie (19, 27,1 %). Il y a eu deux décès maternels, soit un taux de létalité de 2,9 %.
CONCLUSIONS: L’avortement à risque reste une cause importante de mortalité et de morbidité maternelles dans notre contexte. L’amélioration de l’accès à des contraceptifs modernes efficaces et la libéralisation de nos lois sur l’avortement réduiront la morbidité et la mortalité maternelles dues à l’avortement à risque.
UNASSIGNED: Planification familiale, Avortement illégal/criminel, morbidité et mortalité maternelles, Produit de la conception retenu, Besoin non satisfait.

Recent increases in maternal mortality and persistent disparities have led to speculation about why the U.S. has higher rates than most high-income countries. The aim was to examine the impact of changes in state-level factors plausibly linked to maternal mortality on overall rates and by race/ethnicity.
This quasi-experimental, population-based, difference-in-differences study used 2007-2015 National Vital Statistics System microdata mortality files from 38 states and DC. The primary exposures were 5 state-level sexual and reproductive health indicators and 6 health and economic conditions. Maternal mortality rate was defined as number of deaths of women while pregnant or within 42 days of termination of pregnancy per 100,000 live births. A difference-in-differences zero-inflated negative binomial regression model was estimated using the race/ethnicity-age-state-year population as the denominator and adjusting for race/ethnicity, age, state, and year. Data were analyzed in 2017-2018.
There were 4,767 deaths among women up to age 44 years, resulting in a maternal mortality rate of 17.9. Reducing the proportion of Planned Parenthood clinics by 20% from the state-year mean increased the maternal mortality rate by 8% (incidence rate ratio, 1.08; 95% CI=1.04, 1.12). States that enacted legislation to restrict abortions based on gestational age increased the maternal mortality rate by 38% (incidence rate ratio, 1.38; 95% CI=1.03, 1.84). Planned Parenthood clinic closures negatively impacted all women, increasing mortality by 6%-15% across racial/ethnic groups, whereas gestational limits primarily increased mortality among white women.
Recent fiscal and legislative changes reducing women\'s access to family planning and reproductive health services have contributed to rising maternal mortality rates.

Uganda hosts 1.4 million refugees and conflict-affected people. Widely regarded as the best place in Africa to be a refugee, Uganda\'s policies encourage self-sufficiency and local integration. However, abortion is legally restricted and recent studies suggest that displaced women and girls have persistent unmet sexual and reproductive health needs. In 2017, we conducted a multi-methods study to assess the reproductive health needs of displaced Congolese women in camp- and urban-based settings in Uganda. Our project focused on maternal health and delivery care, contraception, and abortion/post-abortion services and the intersection of these issues with sexual and gender-based violence. We interviewed 11 key informants, facilitated 4 focus group discussions with refugee women, and conducted 21 in-depth interviews with Congolese women of reproductive age to understand better knowledge, attitudes, practices, and services. Using both inductive and deductive techniques, we employed a multi-phased analytic plan to identify content and themes and triangulate and interpret findings. Our results suggest that Congolese refugees in Uganda are unable to navigate the legal restrictions on abortion and are engaging in unsafe abortion practices. This appears to be the case for those living in both camps and urban areas. The legal restrictions on induced abortion pose a barrier to the provision of post-abortion care. Efforts to ensure access to comprehensive abortion care should be prioritised and providing information and support to women in need of post-abortion care is imperative.

Canada decriminalized abortion, uniquely in the world, 30 years ago. We present the timeline of relevant Canadian legal, political, and policy events before and since decriminalization. We assess implications for clinical care, health service and systems decisions, health policy, and the epidemiology of abortion in the absence of criminal legislation. As the criminal abortion law was struck down, dozens of similar private member\'s bills, and one government bill, have been proposed, but none were passed. Key findings include that initially Canadian provinces attempted to provide restrictive regulations and legislation, all of which have been revoked and largely replaced with supportive policies that improve equitable, accessible, state-provided abortion service. Abortion rates have been stable over 30 years since decriminalization, and a falling proportion of abortions occur late in the second trimester. Canada demonstrates that abortion care can safely and effectively be regulated as a normal component of usual medical care.

Despite adopting a progressive legal and policy framework informed by internationally recognized human rights norms and values, Malawi has not complied with the obligation to explain its abortion law in accordance with legal and human rights standards. In 1930, the colonial government adopted a Penal Code derived from English criminal law, containing provisions regulating access to abortion, but has not undertaken measures to explain when abortion is lawful. What constitutes legal abortion has never been clarified for health providers and potential clients. Consequently, eligible girls and women fail to access safe and legal abortion. The Malawi Law Commission, following its review of the colonial abortion law, has proposed liberal changes which, if implemented, would expand access to safe abortion. However, the immediate step the government ought to take is to clarify the current abortion law, and not to wait for a new law expected to materialize in the indeterminate future.

BACKGROUND: When faced with an unintended pregnancy, some women choose to undergo an unsafe abortion, while others do not. This choice may depend on long-term contraception that shapes the fertility goals of women, along with many other risk factors. We assessed the risk for unsafe abortion associated with contraceptive practices based on women\'s long-term behaviour, and its likely modification by the use of different types of contraceptives among women in Sri Lanka.
METHODS: An unmatched case-control study was conducted in nine hospitals among 171 women admitted for care following an unsafe abortion (Cases) and 600 women admitted to same hospitals for delivery of an unintended term pregnancy (Controls). Interviewer-administered-questionnaires assessed their socio-economic, reproductive and fertility (decisions on family size, family completion) characteristics, contraceptive method last used (traditional, modern), reasons for discontinuation/never-use, and contraceptive practices assessed at different time points. Using several regression models, the risk of abortion was assessed for \'non-use\' of contraception against \'ineffective use\' at conception; for non-use further categorised as \'never-use\', \'early-discontinuation\' (discontinued before last birth interval) and \'late-discontinuation\' (discontinued during last birth interval); and for any interaction between the contraceptive practice and contraceptive method last used among the ever-users of contraception.
RESULTS: At conception, \'non-use\' of contraception imparted a two-fold risk for abortion against ineffective use (adjusted-OR = 2.0; 95% CI: 1.2-3.2). The abortion risk on \'non-use\' varied further according to \'early\' (adjusted-OR = 1.7; 95% CI: 1.1-3.1) and \'late\' (adjusted-OR = 2.3; 95% CI: 1.5-3.6) discontinuation of contraception, but not with \'never-use\' (crude-OR = 1.1; 95% CI: 0.6-2.3). Among the ever-users, the risk of abortion varied within each contraceptive practice by their last used contraceptive method and reasons for discontinuation. A significant interaction between modern contraceptives and early discontinuation (adjusted-OR = 1.4; 95% CI = 1.1-3.1) demonstrated a seven-fold abortion risk for early discontinuation of modern methods against its ineffective use. In particular, hormonal methods seemed to be responsible for this risk (51.1% cases versus 42.5% controls).
CONCLUSIONS: Long-term contraceptive practices showed varying risk for abortion, and was further modified by early discontinuation of modern contraceptives. This knowledge should be applied during postnatal visits by public-health staff.

BACKGROUND: Literature shows that choice for unsafe abortion is often driven by poverty. However, factors related to the family formation behaviour of women are also implied as determinants of this decision. This study assessed which family formation characteristics of women are associated with the risk of unsafe abortion, without being confounded by their low socio-economic status among Sri Lankan women admitted to hospital following post-abortion complications.
METHODS: An unmatched case-control study was conducted in nine hospitals in eight districts in Sri Lanka among 171 women with post-abortion complications following unsafe abortion (Cases) and 600 postpartum mothers admitted to same hospitals during the same period for delivery of term unintended pregnancies (Controls). Interviewer-administered-questionnaires obtained demographic, socio-economic and family formation related characteristics. Risk factors of abortion were assessed by odds-ratio (OR), adjusted for their socio-economic status in logistic regression analysis.
RESULTS: Low socio-economic status, characterised by low-education (adjusted OR = 1.5; 95 % CI = 1.1-2.4) and less/unskilled occupations (2.3; 1.4-3.6) was a significant risk factor for unsafe abortion. Independent of this risk, being unmarried (9.3; 4.0-21.6), failure in informed decisions about desired family size (2.2; 1.4-3.5), not having a girl-child (2.2; 1.4-3.4) and longer average birth intervals (0.7 years; 0.6-0.8) signified the vulnerability of women for unsafe abortion. Cases were as fast as the controls in their family completion (4.3 versus 4.5 years; p = 0.4), but were at increased risk for abortion, if their average birth intervals (including the last one) were longer. Previous contraceptive use, age at reproductive events or partners\' characteristics did not impart any risk for abortion.
CONCLUSIONS: Low socio-economic status is not the most influencing risk factor for unsafe abortions leading to complications, but many other factors in relation to their family formation characteristics that are independent of their low socio-economic status.

BACKGROUND: Abortion has been legal in Nepal since 2002 and the country has made striking progress in rolling out induced abortion services. It led to well-known changes in reproductive behavior, however knowledge about legislation and abortion experience by female youth has been least investigated. This paper is an attempt to examine knowledge about legislation of abortion and abortion experiences among female youth in Nepal.
METHODS: This paper uses data from the Nepal Demographic and Health Survey (NDHS 2011). The analysis is confined to female youth aged 15-24 (n = 5050). Both bivariate and multivariate analyses have been performed to describe the knowledge about law and experience of abortion. The bivariate analysis (chi-square test) was applied to examine the association between dependent variables and female youth\'s demographic, socioeconomic, and cultural characteristics. Besides bivariate analysis, the net effect of each independent variable on the dependent variable after controlling for the effect of other predictors has also been measured through multivariate analysis (logistic regression).
RESULTS: Only two-fifth (41%) female youth was aware of abortion legislation in the country. Knowledge on at least one condition of abortion law is even lower (21%). Less than two percent (1.5%) female youth reported that they ever had an abortion. The multivariate analysis found that the knowledge and experience of abortion varied with different settings. Youth aged 20-24 [adjusted odds ratio (aOR) = 1.3; 95% CI 1.7-5.0)], who have higher education (primary aOR = 1.89, ; 95% CI 1.5-2.5 secondary aOR = 4.6; 95% CI 3.7-5.9), who were from rich households (aOR = 1.5; 95% CI 1.2-1.7), who had high autonomy (aOR = 1.29; 95% CI 1.02-1.64) were more likely to be aware compared to their counterparts about legislation of abortion. In the other hand, female from Dalit (aOR = 0.55; 95% CI 0.5-0.7 and Janajati aOR = 0.72; 95% CI 0.6-0.8) caste, who were married (aOR = 0.80; 95% CI 0.7-0.9), who were from Muslim (aOR = 0.54; 95% CI 0.3-0.9) and who resided in Hill (aOR = 0.63 ; 95% CI 0.5-0.8) and Terai/plain area (aOR = 0.74; 95% CI 0.6-0.9) were less likely to be aware about the law. Similarly, female youth who have knowledge on abortion law (aOR = 2.8; ; 95% CI 1.6-4.8), who have primary (aOR = 5.2; 95% CI 1.6-16.9) and secondary education (aOR = 3.8; 95% CI 1.2-12.8), married (aOR = 7.7; 95% CI 3.8-12.9), who had higher number of children ever born [1-2 children aOR = 1.9; 95% CI 1.1-3.6 and 3 or more children aOR = 3.4; 95% CI 1.1-10.9), who were from rich households (aOR = 2.62 ;95% CI 1.3-5.4), who have high autonomy (aOR = 3.0; 95% CI 1.6-5.8), who had experienced sexual violence (aOR = 1.91; 95% CI 1.1-8.7) were more likely to undergone abortion compared to their counterparts.
CONCLUSIONS: Knowledge about legislation of abortion and conditions of abortion law is low among female youth. Awareness program should target these youth as they are more likely to be sexually active. There is a need of comprehensive education about abortion to these youth which can help eventually reduce unsafe abortion that take a large toll on women\'s life.

BACKGROUND: In Zanzibar, a semi-autonomous region of Tanzania, induced abortion is illegal but common, and fewer than 12% of married reproductive-aged women use modern contraception. As part of a multi-method study about contraception and consequences of unwanted pregnancies, the objective of this study was to understand the experiences of Zanzibari women who terminated pregnancies.
METHODS: The cross-sectional study was set in Zanzibar, Tanzania. Participants were a community-based sample of women who had terminated pregnancies. We carried out semi-structured interviews with 45 women recruited via chain-referral sampling. We report the characteristics of women who have had abortions, the reasons they had abortions, and the methods used to terminate their pregnancies.
RESULTS: Women in Zanzibar terminate pregnancies that are unwanted for a range of reasons, at various points in their reproductive lives, and using multiple methods. While clinical methods were most effective, nearly half of our participants successfully terminated a pregnancy using non-clinical methods and very few had complications requiring post abortion care (PAC).
CONCLUSIONS: Even in settings where abortion is illegal, some women experience illegal abortions without adverse health consequences, what we might call \'safer\' unsafe abortions; these kinds of abortion experiences can be missed in studies about abortion conducted among women seeking PAC in hospitals.

BACKGROUND: Unwanted pregnancy has affected different aspects of our life. Researchers point out if a child\'s birth is unwanted, an increase in maternal issues can be observed. The aim of this study was to describe the women\'s viewpoints regarding unwanted pregnancy.
METHODS: This qualitative study using content analysis was employed in Shiraz University in 2013-2014. 20 women with unwanted pregnancy were chosen using purposeful sampling. Data were gathered through semi-structured interviews and trustworthiness of them was evaluated.
RESULTS: Findings of this study, according to the participants\' experience, revealed maternal emotions like embarrassment for getting pregnant, mother\'s own negative affection, concerns about missing family and other children, and terminating the pregnancy through illegal abortion, the husband\'s disagreement about the termination, blaming themselves for thinking about abortion or illegal abortion, and concern about their guilt feeling. Another finding was family problems like husband\'s behavior and his negative outlook towards his child and fetus. The next category belonged to anxiety about the future of their child, including economic, social and relational problems, and suppression of the children\'s logical expectations. The last finding was the lack of maternal emotional support.
CONCLUSIONS: Unwanted pregnancy\'s effects on the mothers and infants\' health are considerable. A closer observation by family and health care providers for unwanted pregnancies and its results is recommended; therefore, they should be taken care of as high risk pregnancies, requiring family support.