Where contraception is available and affordable, abortion should rarely be necessary; when it is necessary, however, it should be accessible and safe. Abortion rates have declined in the last decade, but up to 20% of all deaths during pregnancy in several countries are due to unsafe abortion. In some countries, there are more abortions than births. The countries of central and eastern Europe are estimated to have the highest abortion rates in the world.
The challenges are:
- poor-quality services;
- delays in getting an abortion;
- barriers to abortion after 12 weeks gestation;
- no legal framework to decriminalize abortion;
- no standards of performance;
- medical abortion performed without up-to-date skills;
- abortions not covered by public health expenditure or health insurance; and
- no laws and policies to ensure that people have access to reproductive education, information and services.
WHO develops norms, tools and guidelines on reproductive health in general and abortion services in particular, and supports countries in reforming their health systems. Its role includes:
- distributing existing evidence on abortion;
- assisting Member States in evaluating health systems' response to the needs of women with unwanted pregnancies;
- promoting methodology in quality control of abortion services; and
- training of trainers in, for example, counselling and abortion care.
Countries such as Ireland, Luxembourg, Spain, Kyrgyzstan, the Republic of Moldova, Romania and Tajikistan have asked for WHO/Europe's assistance to help improve access to and the quality of their abortion services, and work is currently ongoing using WHO methodology with several others including Armenia, the Russian Federation and Ukraine.
Internationally agreed policy
In international fora, abortion is mainly discussed in the context of reducing the impact of unsafe abortions on women's health, but it is about women's right to affordable and accessible abortions.
One of the objectives of WHO/Europe's regional strategy on sexual and reproductive health (2001) was to reduce the number of abortions by:
- providing adequate reproductive health services;
- integrating family planning into primary health care policies and programmes;
- removing legal obstacles to contraceptive choices.
WHO's global reproductive health strategy (2004) identified unsafe abortion as a preventable cause of maternal deaths and injuries, and the steps needed to prevent them, including:
- strengthening family planning services to prevent unintended pregnancies;
- training health-service providers in modern techniques and equipping them with appropriate drugs and supplies for gynaecological and obstetric care;
- providing social and other support to women with unintended pregnancies;
- to the extent allowed by law, providing abortion services in primary health care.
Similarly, the 1994 Programme of Action of the United Nations International Conference on Population and Development agreed that:
"In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and nongovernmental organizations are urged to strengthen their commitment to women's health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion, through expanded and improved family-planning services. Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be given to eliminate the need for abortion."
"Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. Post-abortion counselling, education and family-planning services should be offered promptly, which will also help to avoid repeat abortion."
Unsafe abortion is defined as a procedure for terminating an unwanted pregnancy either by people lacking the necessary skills or in an environment lacking the minimal medical standards or both. Preventing unsafe abortion involves:
- finding out what is happening now;
- basing policies on what works (evidence);
- improving technologies;
- building capacity, training staff;
- testing interventions.
The cost of conducting a safe abortion is thought to be one tenth of the cost of treating the consequences of an unsafe one.