Although the past two decades have seen major decreases in most leading causes of maternal deaths worldwide, one glaring exception remains: unsafe abortion. Estimates put the number of unsafe abortions each year at over 25 million, with 97% of them in developing countries, and which lead to at least 22,800 deaths and millions of serious complications. Since MSF projects often see patients suffering from the severe, potentially life-threatening effects of unsafe abortion, we have expanded our efforts to help women access safe abortion care and to find ways of providing it at our projects. In 2019 we provided over 21,500 safe abortions to women in 30 countries.
Safe abortion facts
What are safe versus unsafe abortions?
An abortion is considered safe if it is done with a method recommended by the World Health Organization and appropriate to the pregnancy duration, and if the person providing or supporting the abortion is trained. If either of these conditions is not met, the abortion is unsafe. The two main categories for unsafe abortions are “less safe” and “least safe.” Less safe abortions involve either an outdated, unsafe method or a lack of access to proper information, while least safe abortions involve both. Examples we see in our projects include Inserting sharp sticks or needles into the uterus, ingesting harmful substances such as bleach, battery acid or chlorine, using external force on the abdomen, and using medications incorrectly and without appropriate support. Out of 25 million unsafe abortions each year, almost one-third occur under the least safe, most dangerous conditions.
What is safe abortion care?
Safe abortion care can be provided either with medications or with an outpatient procedure.
Medication abortion, meaning an abortion with pills, involves two drugs: mifepristone and misoprostol. Mifepristone blocks progesterone, one of the main hormones of pregnancy, while misoprostol causes the uterus to contract and push out the pregnancy in a process similar to miscarriage. If mifepristone is not available, then misoprostol alone can also be used to induce an abortion. Misoprostol is widely available around the world since it is also used to treat other complications of pregnancy, including spontaneous miscarriage and post-partum bleeding.
An abortion with pills is over 95% effective and is extremely safe, with less than a 1% chance of severe complications. The risk of death from a safe abortion is lower than from an injection of penicillin or from carrying a pregnancy to term. An abortion with pills is so safe that most of the time, women can take the medications at home without routine follow-up—they need to seek care only if they have a question or problem. Abortion does not cause infertility, mental health problems, or problems with future pregnancies.
Providing or supporting an abortion with pills doesn’t require any special technology or medical interventions. According to the World Health Organization, routine blood tests, ultrasound, and follow-up are unnecessary; a safe abortion with pills requires only accurate information and quality medications. Because of this, medication abortion has expanded access to safe abortion care for millions of women and girls around the world—especially in low-resource and crisis settings.
Manual vacuum aspiration (MVA) is a simple outpatient procedure that involves inserting a narrow plastic tube into the uterus and safely removing the pregnancy using suction. MVA can be performed by many different kinds of health care workers (including doctors, nurses, and midwives) and in basic health care centers (without surgical services) until 14 weeks of pregnancy. It can also be used to treat abortion-related complications such as incomplete abortion.
Who is most at risk of unsafe abortion?
Anyone with an unwanted pregnancy who cannot access safe abortion services is at risk of injury or death from unsafe abortion. Barriers to safe abortion, like high cost, legal restrictions, stigma, and objections from health-care providers all contribute to higher rates of unsafe abortion. The risk of complications also increases when unsafe abortions are performed later in pregnancy.
Abortion shines a light on social injustices and inequities. Poor women, women of color, and women living in remote areas are disproportionately cut off from safe abortion services. Women and girls trapped in war, crisis, and conflicts often face additional barriers to accessing abortion care. Mortality rates from unsafe abortion are highest in Africa, which sees 29% of all unsafe abortions but about 62% of unsafe abortion-related deaths.
What are the medical consequences of unsafe abortion?
When safe abortion care is inaccessible, many women and girls turn to dangerous methods of ending their pregnancies, regardless of safety and legal restrictions. Major life-threatening complications include hemorrhage (severe bleeding), infection and sepsis (severe body-wide blood infection), perforation of the uterus, and injury to the genital tract or other internal organs. Women who access abortion medications on the black market may also suffer complications due to low-quality drugs, incorrect dosing, or inadequate information. Even if effective at terminating the pregnancy, unsafe abortion can lead to long-term health consequences such as infertility, chronic pain, and emotional and psychological trauma.
How are unsafe abortions treated?
Much of the mortality associated with unsafe abortion is due to delayed treatment. Abortion-related stigma often plays a big role in these delays: women may be afraid to seek care for complications from unsafe abortion because they fear being reported to the authorities, treated badly by health care providers, and/or seen by someone they know.
Once at the hospital, women who undergo unsafe abortions may require blood transfusions to treat heavy blood loss, antibiotics to treat infection and sepsis, major reparative surgery of internal organs, or even a hysterectomy (removal of the uterus).
How can unsafe abortion related injuries and deaths be prevented?
Prevention begins with reducing the number of unsafe abortions, which in turn requires access to health services—such as sexuality education and contraceptive care—aimed at preventing unwanted pregnancies. However, education and contraception alone are not enough: women and girls also need access to timely, confidential, and safe abortion care services. Reducing barriers to obtaining these services is essential to saving lives and preventing injuries and disability.
What are the barriers to accessing safe abortion care?
Abortion is still partly criminalized in many countries, although nearly all of them make exceptions to save the woman’s life. Legal frameworks around abortion are complex and nuanced, and can be difficult for patients and medical providers to navigate. Legal limitations are especially concerning given clear evidence that they do not lower the number of abortions but instead make unsafe abortion more likely. Given this mounting evidence, in recent years many countries have revised their laws to permit abortion under a broader set of circumstances, with the result that maternal deaths have decreased. For example, since South Africa's post-apartheid government adopted the Choice of Termination of Pregnancy Act (CTOP) in 1996, deaths from unsafe abortion have dropped by 91%.
Beyond the legal barriers, many women experience shame, social stigma, and negative attitudes about the circumstances that led to their unwanted pregnancy, or to the abortion itself—which in turn can create obstacles to accessing care. Common obstacles include verbal abuse or social rejection from family and friends, misrepresentation or lack of information about laws regarding abortion, and rejection, stigma, and ignorance within the health system.
The COVID-19 pandemic presents other powerful barriers to access. In responding to the pandemic many governments have deprioritized sexual and reproductive health, leading to funding cuts and thousands of clinic closures around the world as resources are diverted into COVID-19 activities. Lockdowns, curfews, travel bans, and loss of safe public transportation options also make it difficult or impossible for women to reach health centers.
How MSF responds
MSF considers access to safe abortion care as a critical, lifesaving part of comprehensive reproductive health care, one that reduces maternal mortality and suffering. Our commitment to this issue stems from experience at our projects, where every day we see suffering and death caused by unintended pregnancies and unsafe abortions. In 2019, we treated nearly 26,000 women and girls for abortion-related concerns and complications, many of which resulted from unsafe attempts to terminate pregnancy.
Yet even though we were treating the complications of unsafe abortion daily at our projects, in the mid-2010’s we came to realize that we were not doing enough to improve access to safe abortion care despite our longstanding policy to do so. To figure out why, we took a systematic look at our internal challenges in providing this care and at how we could tackle them. This process led in 2016 to the establishment of an MSF “Task Force for Safe Abortion Care” that helped us identify our internal barriers, step up our programming, and develop strategies to improve access to safe abortion care for our patients.
Since then, we have developed a new package of comprehensive programs designed to make safe abortion, post-abortion care, and contraception more available. In 2019, 91 MSF projects in 30 countries provided safe abortion care. More recently, in response to severe constraints due to COVID-19, we are adapting the ways we deliver these essential services—by reducing the time patients must spend in health facilities in favor of more community-based activities, building up remote support of services and expanding the use of self-care models. We also publicly speak out against harmful governmental policies like the U.S. Global Gag Rule (rescinded in January 2021) and other efforts to limit access to care, and we share evidence-based, factual information about safe abortion. Lastly, we conduct research to assess the severity and treatment of complications from unsafe abortion in conflict-affected settings.
Addressing internal barriers
In 2016, the Task Force for Safe Abortion Care identified several barriers within MSF that impeded our ability to systematically provide safe abortion care at our projects. These included abortion-related stigma, myths and misconceptions, lack of clinical knowledge, concerns about legal limitations, and fears about community acceptance. One of the most effective ways we found to overcome these barriers was by implementing the “Exploring Values and Attitudes” (EVA) Workshop. EVA workshops facilitate an open-minded, honest, and critical reflection about values and attitudes towards safe abortion care. Everyone on staff was welcome to join the workshops, from headquarters staff to nurses, midwives, cleaners, and drivers. Through more than 240 EVA workshops conducted in over 35 countries, we found that open dialogue helped staff learn from other perspectives and better understand the medical need for safe abortion services.
The Task Force also conducted field support visits to ten MSF pilot projects that were not routinely or consistently providing safe abortion services. It conducted EVA workshops and clinical trainings, assessed threats and risks, engaged in discussions with community leaders and other local stakeholders, developed implementation strategies, and set up data collections systems to help integrate safe abortion care into our regular services. This strategy seems to have created lasting change, since each of the ten MSF projects visited by the Task Force, along with 80 others throughout the world, now provide safe abortion care. In 2019 we provided 21,546 safe abortions.
Comprehensive package of reproductive health care services
Providing emergency care for women suffering with complications from an unsafe abortion has long been part of our women’s health programs. Treatment may involve blood transfusions for blood loss, major surgery to repair damaged organs, intravenous fluids and antibiotics for infections and sepsis, or misoprostol to treat incomplete abortion. But in the worst-case scenarios, women die because they reach the hospital too late and their condition is already too critical. These emergencies are all the more heart-wrenching because nearly every one of them could have been prevented had the women been able to access safe abortion care.
To help save lives and reduce suffering from unwanted pregnancy and unsafe abortion, our comprehensive package of reproductive health care now goes beyond treating abortion-related complications to include contraception services and safe abortion care.
Working with Ministries of Health and other non-governmental healthcare providers, our projects aim to provide a wide variety of contraceptive methods to meet the different needs of our patients, including implants, intrauterine devices, injectables, oral contraceptive pills, and condoms. In 2019, we provided over 454,000 consultations for contraception. Providing effective contraceptive services often means adapting our projects to settings where ongoing crisis or conflict may restrict women’s access to reproductive health care. For example, many women in Central African Republic travel long distances to reach contraceptive services, and when conflict escalates in their region the journey can become too dangerous. The COVID-19 pandemic has also impeded women’s access to contraceptive services because of movement restrictions and clinic closures. For these reasons, we are expanding the ways we deliver care to include telehealth services, longer refills on contraceptive pills, and longer-term methods of contraception.
MSF guidelines and policies include information on abortion up to 22 weeks of pregnancy and provide guidance on care before, during, and after the abortion process. Before the abortion, it is important that patients have complete, easy-to-understand information so they know what to expect and can give their voluntary consent. It also includes helping the woman make a plan that suits her needs, managing pain during and after the abortion, identifying other needs for support, and discussing post-abortion services like contraception.
Most women opt for the medication option (an abortion with pills). The majority of medication abortions we provide are done on an outpatient basis, often by nurses or midwives and without routine blood tests or ultrasounds, in accordance with World Health Organization guidelines. Patients can take the pills at home and return to the clinic only if they have concerns. To adapt to COVID-19 related constraints, some MSF projects are now piloting ways to work with community health workers, peer educators, and hotlines in further supporting home-based medication abortion safely and effectively. But it is still not enough—we and other global health actors must continue to innovate and develop more locally- driven and -tailored responses that expand access to contraception and safe abortion for the most vulnerable.
Training, education and advocacy
At some of our projects we provide mentoring and guidance, institutional back-up, and further training for health care providers who work in settings where health services are extremely stretched. Trainings and workshops on maternal deaths from unwanted pregnancies, unsafe abortions, and the role of safe abortion care are being facilitated around the world for MSF staff, Ministry of Health colleagues, and other partners.
We also provide educational tools to other humanitarian actors on how to provide safe abortions in low-resource settings. In January 2020 MSF launched a free, open-source, evidence-based online course on medication abortion. Developed in partnership with HowToUseAbortionPill.org, its five animated videos provide information on unsafe abortion and how to safely administer an abortion with pills. The goal is to make sure everyone—humanitarian workers, health care workers, and anyone else who wants to know—has access to accurate information about safe abortion.
Beyond our medical activities, MSF speaks out on the medical need for life-saving safe abortion care. We share the stories of patients who lack access to care, and of doctors and nurses who see the devastating effects of unsafe abortion every day. We also speak out against harmful governmental policies and other barriers to safe abortion care and to sexual and reproductive services more broadly.
Many of our projects that provide maternal care are in fragile, conflict-affected settings which often lack visibility on abortion-related medical care and complications. To shed light on this issue, MSF and its research arm, Epicentre, have partnered with the Guttmacher Institute, Ipas, and the Ministries of Health of three African countries (Democratic Republic of Congo, Central African Republic, and Nigeria) on a research study. Its aim is to assess the burden of abortion-related complications, deaths, and near-fatal events, and the quality of abortion-related care. It is also gathering perspectives from patients who experienced near-fatal complications, seeking to understand their decision-making processes and their pathways to accessing care. The study—the first one conducted on this topic in fragile and conflict-affected settings—will include over 1,200 women who suffered abortion-related complications.