Abortion is one of the most sensitive and controversial issues in sexual and reproductive health and rights, and it's intrinsically linked to contraception and family planning. Not all pregnancies are planned or wanted. Decisions to terminate a pregnancy can be influenced by many factors, including the level of unmet need for contraception and the strength of motivation of women and couples to have small families. These are difficult circumstances to discuss even amongst close friends and family. A small share of wanted pregnancies also end in abortion, because continuing the pregnancy would endanger the woman's health, because of fetal abnormalities, or because a woman circumstances change after she becomes pregnant. According to recent studies, 44 percent of all pregnancies worldwide are unintended, and some 56 percent of these end in induced abortion. Little is known about whether these figures different settings affected by conflict, natural disasters, or large-scale epidemics. Although there is some indication that the need for safe abortion services is likely to increase during an emergency. Globally, unsafe abortion accounts for nearly 10 percent of maternal deaths, most of which occur in low and middle-income countries. Women and girls in humanitarian settings may be at increased risk of unintended pregnancy and unsafe abortion, and require access to safe abortion care. Making pregnancy safer includes fulfilling women and girls rights to access comprehensive sexual and reproductive health services, including the provision of safe abortion care, and timely an appropriate management of unsafe and spontaneous abortion for all women. Termination of pregnancy can be a very safe procedure when performed in accordance with medical guidelines. Conversely, unsafe abortions, those done by unqualified providers or using an outdated or damaging method are both, pose a serious threat to women's health making abortion related complications one of the major causes of maternal mortality around the world. Ensuring the well-being of a woman who has an abortion requires more than a medically safe procedure. Holistically, an abortion can only be considered safe if a woman can have one without the risk of criminal or legal sanction, and without the risk of being stigmatized by her family and her community if they were to learn about her procedure. The World Health Organization defines an abortion as safe if it is provided both by an appropriately trained provider and using a recommended method. Less safe abortions meet only one of these two criteria. For example, if provided by a trained health worker using an outdated method, or self induced by a woman using a safe method without adequate information or support from a trained individual. Least safe abortions meet need their criteria. These are provided by untrained people using dangerous methods, such as sharp objects or toxic substances. Because abortion is one of the most sensitive and controversial areas of sexual and reproductive health and rights, it is a topic frequently avoided in humanitarian health program planning and implementation. This is itself a barrier to meeting the sexual and reproductive health needs of women and girls in crisis affected settings in addition to the legal, clinical, and social barriers that inhibit care. Although abortion is legally restricted in most countries, termination of pregnancy is only completely illegal in six countries around the world. In 97 percent of countries, abortions are allowed only when it's necessary to save a woman's life. Sixty percent then extend this to when it's necessary for health reasons, including mental health, and 50 percent allow abortions for pregnancies caused by rape. Legality does not mean that services are widely available though. In many countries, it is entirely possible that a woman in need of a safe medically indicated and legally allowable abortion is not able to find any health care providers to perform the simple outpatient procedure. Stigma interferes with access to safe abortion in a number of ways. In societies throughout the world where sexual activity and childbearing outside of marriage are themselves highly stigmatized, the stigma associated with abortion forces women to prioritize secrecy over safety when seeking care, or other sexual and reproductive health services. Unmarried and young women in particular face steep hurdles to obtaining contraceptive information and services, which places them at heightened risk of unintended pregnancy. Women who fear judgment by their families or health professionals and social sanction in their communities may avoid abortion and post abortion care and medical settings, and seek clandestine abortion procedures instead. Despite these barriers and nearly every crisis affected setting, advancements in three areas have driven improvements and abortion safety over the last few decades. First, the development and dissemination of global and national clinical guidelines has steadily improved the quality of service delivery in countries that permit abortions. Additionally, recommendations related to task shifting service delivery from often scarce doctors to a wider array of trained mid-level providers, and from specialized to primary healthcare facilities have expanded the reach of abortion services. Second, access to post abortion care to treat complications of unsafe abortion has also improved. Again, due in large part to the publication of guidelines and establishment of global communities of practice. Recognizing that untreated complications from clandestine and often unsafe abortions can lead to hemorrhaging sepsis and even death. National governments have agreed that post abortion care is a necessary component of maternal health care, including in countries where abortion is banned altogether. Finally, a powerful trend in making abortion safer worldwide is increasing access to safer methods of procedures. Namely, shifting away from surgical abortion to medical abortion through the use of drugs called, mythoprostol and misoprostol, or misoprostol alone. Use of these drugs allows abortions to be provided at lower levels of health facilities, or even by women themselves in their homes. There are a number of key strategies and best practices for reducing unsafe abortion in humanitarian settings. The first is increasing availability of contraceptive services. Preventing unintended pregnancies would dramatically decrease the need for abortion. By satisfying unmet need for modern contraception, the numbers of unintended pregnancies, unplanned births, and abortions would all drop by almost three-fourths from current levels. Another key step in reducing unsafe abortion is ensuring widespread understanding of national legal frameworks and restrictions. As mentioned earlier, nearly all countries allow for abortion when it is a life-saving procedure, but this may not be widely known to health care providers. Understanding the indications and requirements for terminating a pregnancy will allow health care workers to better meet the needs of their clients in a confident and timely manner. Evidence suggests that stigmatizing attitudes play a powerful role in restricting women's access to safe abortion care in crisis and fragile settings. Whether abortion is legal or illegal, much more needs to be done to reduce stigma through public education campaigns and provide training on non-judgmental care and treatment. Health care worker bias is a very real challenge in abortion care. But one that can be addressed to adaptation and use of existing resources, such as values clarification, attitude transformation, workshops and approaches, which have proven successful with the abortion care in other settings. Combating stigma is especially important for younger women and unmarried women, who may face higher barriers to accessing sexual and reproductive health services than their older and married counterparts. Global efforts to provide women with medically accurate information about medical abortion, including regimens for early abortion, have inspired harm reduction programming. Dissemination of information through telemedicine services and websites, and the establishment of call centers in contexts where access to safe services is limited or unavailable. Findings from implementation research and some protracted conflict settings showed that community based distribution of drugs for medical abortion can be a safe effective and culturally resonant and strategy for increasing access to services, even in a legally restricted low-resource conflict affected setting. Finally, ensuring that all health facilities are able to manage problems during childbirth have staff trained and supplies ready to provide post abortion care, will help mitigate the negative consequences of unsafe or incomplete abortions. This includes being able to perform the necessary clinical procedures, pain management, and canceling on self care and contraceptive options.
