Reductions in abortion-related mortality following policy reform: evidence from Romania, South Africa and Bangladesh

Unsafe abortion and inadequate post-abortion care are significant contributors to maternal mortality, which is a major cause of death among women of reproductive age worldwide. An estimated 21.6 million unsafe abortions occurred globally in 2008, many of them in developing countries with highly restrictive abortion laws [1]. Approximately 47,000 women die annually from complications of unsafe abortions, a rate of 220 deaths per 100,000 unsafe abortions [1]. These deaths constitute 13% of maternal mortality worldwide, with proportions as high as 49% in some settings [1,2]. In addition to death, approximately 5 million women in the developing world require hospitalization for complications resulting from unsafe abortions, and these complications can lead to long-term health problems [3].Unsafe abortions, and associated morbidity, mortality and socioeconomic impact, are not inevitable. Unsafe abortion is more likely in settings where there are strong legal prohibitions or where more liberal laws have not translated into access to safe and comprehensive services. The 82 countries with the most restrictive abortion legislation are also those with the highest incidence of unsafe abortions and abortion mortality ratios [4]. In such settings, women often fear legal reprisal or are otherwise unable to access necessary post-abortion care. An estimated 15-25% of women in need of medical treatment for abortion-related complications do not seek care [3]. In many cases women who do try to access the health care system for post-abortion care are met with stigma and given sub-par medical treatment, further compounding the risk of morbidity and mortality [5].Restrictive abortion policies can also have reverberating social and economic effects on women, their children and larger communities. By 2007, 67 countries had legislation explicitly permitting legal termination on the grounds of economic or social hardship, recognizing the potential impact of unwanted pregnancy and unsafe abor