Mahmoud F FathallaI,*; Rebecca J CookII
IAssiut University, 71414 Assiut, Egypt
IIUniversity of Toronto, Toronto, Canada
The World Health Organization (WHO) has released an update of its 2003 publication Safe abortion: technical and policy guidance for health systems.1 The guidance contained in the original publication has been widely used by governments, nongovernmental organizations, providers of women's health services and women's health and human rights advocates. The updated guidance is thus certain to be well received and put to good use by all public health officials and medical personnel who care for women's health and rights.
The substantial revisions in the 2012 update reflect developments not only in safe abortion methods and clinical care, but also in the application of human rights principles in policy-making and in legislation related to induced abortion. The updated publication was prepared in accordance with WHO standards and requirements for evidence-based guideline development and the draft recommendations were reviewed and revised by an international panel of experts. Notably, these recommendations provide guidance about the range of safe options available to women seeking an elective abortion and highlight the importance of having the woman participate in the choice of abortion method, pain control and post-abortion contraception.
Some women will obviously always refuse to have an induced abortion, a subject that has sparked heated controversy in every epoch and continues to do so today. However, exposure to unsafe abortion is gravely detrimental to women's health and human rights. At present, an estimated 22 million abortions continue to be performed annually under unsafe conditions throughout the world. About 47 000 women die every year from the complications of these unsafe abortions and an additional 5 million are left disabled.2 Access to safe elective abortion early in pregnancy could prevent nearly every one of these deaths and cases of disability.
Women throughout history have resorted to induced abortion to deal with unwanted pregnancy, but often at risk to their health or even their lives. Although use of contraceptives has resulted in decreased rates of unintended pregnancy, it has not eliminated the need for safe elective abortion because every method of contraception has an intrinsic failure rate, even if used strictly as prescribed. According to estimates based on 2007 data on contraceptive use and failure rates, every year approximately 33 million women worldwide get pregnant accidentally while practising contraception.1
Unsafe induced abortion is not only a public health problem; it is also a human rights issue.3 Governments are obligated by their national constitutions or by legally binding international human rights conventions to protect a set of fundamental human rights, namely, the right to the highest attainable standard of health; to non-discrimination; to life, liberty and personal security; to education and information, and to freedom from inhuman and degrading treatment. WHO's 2012 guidance explains how national courts and regional and international human rights bodies, including the United Nations treaty monitoring bodies, have increasingly applied human rights principles to facilitate women's transparent access to safe abortion services.1 As unsafe elective abortion is a multifaceted problem involving politicians, lawyers, religious groups and medical staff, addressing the human rights of women who face an unplanned pregnancy may facilitate helpful dialogue among these stakeholders.
In a consensus statement issued in 1999, the United Nations General Assembly prescribed that "in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible".4 Restrictive abortion laws are not associated with lower abortion rates.5 In countries where induced abortion is highly restricted by law, safe abortion has frequently become the privilege of the rich, while poor women are left with little choice but to resort to unsafe providers. Even in places where abortion is allowed only to save a woman's life or to protect her health, trained providers and good services and treatments must be made available to manage the complications of unsafe abortion.
In updating its guidance on safe abortion, WHO, with support from an international consensus and prompted by human rights obligations, has responded to a major neglected public health need of women. The writers of this editorial, a health professional and a lawyer, submit that until abortion is decriminalized, the tragedy of unsafe abortion will continue to haunt us and to threaten the life, health and rights of women. Furthermore, research aimed at developing simpler, improved methods for performing induced abortion has the potential to save the lives of millions of women globally.
Competing interests: None declared.
1. Safe abortion: technical and policy guidance for health systems. 2nd ed. Geneva: World Health Organization; 2012.
2. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. 6th ed. Geneva: World Health Organization; 2011.
3. Cook RJ, Dickens BM, Fathalla MF. Reproductive health and human rights: integrating, medicine, ethics and law. Oxford: Oxford University Press; 2003.
4. Key actions for the further implementation of the Programme of Action of the International Conference on Population and Development: adopted by the twenty-first special session of the General Assembly. New York: United Nations Population Fund; 1999.
5. Sedgh G, Singh S, Shah IH, Åhman E, Henshaw SK, Bankole A. Induced abortion: incidence and trends worldwide from 1995 to 2008. Lancet 2012;379:62532. doi: 10.1016/S0140-6736(11)61786-8 PMID: 22264435
(Submitted: 8 May 2012 Revised version received: 9 August 2012 Accepted: 13 August 2012 Published online: 15 August 2012)