Unwanted Pregnancy – Medical and Ethical Dimensions
J Ravindran, FRCOG
Medical Journal of
Globally, abortion mortality accounts for approximately 13% of all maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high maternal mortality and morbidity from abortion tend to occur together. Unplanned and unwanted pregnancies constitute a serious public health responsibility. While fertility has declined by half in developing countries, the motivation to control and space births has risen faster than the rate of contraceptive use. Preventing maternal mortality and morbidity from abortion in countries where these remain high is a matter of good public health policy and medical practice, and constitutes an important part of safe motherhood initiatives.
A range of positive steps has been taken to reduce deaths and morbidity from abortion in a growing number of countries over the past 15 years. Making abortion legal is an essential prerequisite in making it safe. In this respect, changing the law does matter and assertions to the contrary are ill conceived and unsupported in practice. Although, in many countries, trends towards safer abortion have often occurred prior to or in the absence of changes in the law, legal changes need to take place if safety is to be sustained for all women. Religious laws may also require attention when legal change is being contemplated. There re three main ways of approaching this problem: liberalizing the existing law within the penal or criminal code; partially or fully legalizing abortion through a positive law or a court ruling; and decriminalizing abortion by taking it out of the law.
Women’s health groups and other advocates, parliamentarians and health professionals, can work together to support the right of women not to die from unsafe abortions and to endure they receive treatment for complications. Committed doctors can make a difference by providing treatment for abortion complications, interpreting the law in a liberal way and providing safe services where these are legal as well as training providers in the safest techniques to reduce mortality and morbidity. Although law, policy and women’s rights are central to this issue, making abortion safe is above all a public health responsibility of governments. Moreover, reducing maternal mortality by making abortions safe is also an important part of the international commitment made in Cairo in 1994 at the ICPD and reaffirmed at the Cairo+5 meeting in 1999.
Unwanted pregnancy is defined in the context of this paper as a pregnancy that was not planned for or desired by the couple at the time of conception. Sometimes this may be due to an abnormality in the fetus or illness in the mother. An unsafe abortion is one where the woman decides to undertake a termination of pregnancy by clandestine methods by using an untrained practitioner or dangerous methods that may put her life in danger. Often an unsafe abortion follows an unwanted pregnancy and this premise is made throughout this paper.
Social and Economic Impact of Unsafe Abortion
abortion is defined as a procedure for terminating an unwanted pregnancy either
by persons lacking the necessary skills or in an environment lacking the minimal
medical standards or both. The World Health Organization estimates that as many
as 20 million unsafe abortions take place each year, and that the ensuing
complications cause nearly 80,000 deaths (in other words 400 deaths per 100,000
abortions) – 13 percent of maternal deaths – annually1. Two hundred
women die daily. There is a funeral every 7 minutes in this world of a woman who
has died unnecessarily. However, because of methodological constraints inherent
in abortion-related research, these estimates may not reflect the full extent of
the incidence of unsafe abortion. Hospital based studies suggest that as much as
28 percent of all maternal deaths in
Approximately 75 million of the
175 million pregnancies each year are unwanted. Women experience an unwanted
pregnancy and seek to terminate it for many reasons. Unplanned and unwanted
pregnancies constitute a serious public health responsibility. While fertility
has declined by almost half in developing countries, the motivation to control
and space births has risen faster than the rates of contraceptive use. Once
people decide that they want fewer children, they use a combination of
approaches to achieve this, including modern and/or traditional methods of
contraception and abortion. Fertility declines are sometimes attributed only to
effective contraceptive practice but abortion is also an important
element4. Non-use of contraceptives accounts for the majority of
unwanted pregnancies; although family planning services are more effective and
available than ever before, experts estimate that at least 350 million couples
worldwide lack information about contraceptives and access to a range of modern
family planning methods. Where services exist, women may lack education,
information or decision-making power to use them. Contraceptives also can fail;
between 8 and 30 million pregnancies each year are due to contraceptive failure
– either method-related failure or incorrect use of family planning methods. In
The increasing gap between age at menarche and age at marriage means that there is a longer period during which single women may have an unwanted pregnancy. A lack of access to family planning services for young and single women greatly contributes to the rate of abortions.
Most women use contraception – and abortion where necessary – because they want to be good mothers to the children they already have. Some women are simply not ready or able to have children, and a small and growing number, whose position deserves respect, do not wish to have children at all. Concerns about women’s health, family welfare and poverty are common reasons for abortion, especially among women with several children.
countries, the rate of abortions has been directly influenced by national
population policies. In
Approximately 96 percent of the world’s population lives in countries where abortion is legally permitted when the pregnancy poses a danger to a woman’s life, and more than 72 percent live in countries where a pregnancy can be terminated when it results from rape or incest, or threatens a woman’s physical health. However, women generally do not know what services are available, whether they are eligible for them or whereto get them. Health workers themselves may not be clear about what the law allows and may not be trained to offer abortion-related care.
the law is relatively unrestrictive and allows first-trimester abortion in cases
of economic hardship or on request, health policies and poor quality services
can pose insurmountable barriers. In
Table I: Mortality from unsafe abortions7
Mortality per 100,000 abortions
0.2 – 1.2
The Impact on Personal Health and Well-Being
The World Health Organization estimates that between 10 and 50 percent of women who undergo unsafe abortion need medical care for ensuing complications. One of the most frequent complications is incomplete abortion – the retention of some or all products of conception in the uterus – which can lead to infection and sepsis. Other complications include hemorrhage; vaginal and cervical trauma; infection resulting from unsanitary conditions; and intra-abdominal injury, such as uterine puncture and tears.
these complications can take on women and their families is significant but
difficult to quantify. The number of women who suffer serious, long-term health
problems and permanent disability as a result of complications of unsafe
abortion each year is unknown, but it is estimated to exceed the number of
annual abortion-related deaths. Long-term health problems attributed to unsafe
abortions include chronic pelvic inflammation, permanent or recurrent pain and
secondary infertility. Other health consequences of unsafe abortion are ectopic
pregnancy, increased risks of spontaneous abortion and premature delivery in
subsequent pregnancies. Treatment for these complications can also have a
long-term impact on women’s lives and fertility. For example, uterine
perforation and trauma can necessitate a hysterectomy. In a hospital-based study
In most countries, the majority of women seeking induced abortion are women who are married or live in stable unions and already have several children. When these women die because of abortion-related complications, their families lose a primary caregiver and, in many cases, a primary wage earner as well. Long-term abortion-related health problems and pain can interfere with women’s domestic work, limit their productivity outside the home, constrain their ability to care for their children and affect their sexual relations.
Although the absolute number of abortions performed on adolescents is less than the number performed on older women, young girls suffer disproportionately from abortion complications; in many countries adolescents account for half or more of the women hospitalized for unsafe abortion. Adolescents frequently have poor access to information and services that could help them avoid unwanted pregnancy, and they are less likely than older women to have the social contacts and financial means necessary to obtain a safe abortion. Adolescent women may have more incentive to seek abortion, since an unplanned pregnancy can prevent them from finishing their education and can jeopardize their social, marital and financial future. However, because of ignorance, shame or other reasons, adolescents may delay seeking the procedure until the pregnancy is relatively advanced, which increases their risk for serious complications. If these complications are not treated, they can render a young woman infertile before she ever delivers a child. In the South African study noted above, more than half the women whose septic abortion resulted in a hysterectomy were primagravid and would never be able to bear a child.
The Cost to the Health Sector
Emergency treatment of abortion complications consumes a significant portion of scarce hospital resources in many developing countries. The World Health Organization estimates that the cost of treating a septic abortion is often three or more times that of a normal delivery. Treatment of abortion-related complications often requires several days of hospitalization and staff time, as well as blood transfusions, antibiotics, pain control medications and other drugs. Providing this care consumes enormous health system resources – up to 50 percent of obstetrics and gynecology budgets in some health systems – and depletes both funds and medical supplies for other types of care.
The cost of
treating unsafe abortions at hospitals and health centers is only one partial
measure of its toll on women and countries. Because cost is relatively easy to
quantify, hospital-based cost studies have been used to encourage
decision-makers to ease restrictions on abortion and have convinced health
providers to improve services and training. In
restrict abortion services do not necessarily reduce the incidence of abortion,
just as laws that permit abortion do not necessarily encourage its use. The
attempt to reduce the public health impact of unsafe abortions, legislators all
over the world have begun revising the laws. In some countries, laws governing
abortion have been moved from criminal to health codes. Since 1985, 14
of abortion has probably existed in
Whether the incidence of induced abortion is increasing or decreasing is unclear because of the lack of data. However, clinic and hospital records seem to show an increase in the number of induced abortions.
Abortion Law in
Prior to the Penal Code (Amendment) Act 1989 (Act A727), our laws governing the performance of therapeutic abortions in peninsular Malaysia were identical to the laws that had prevailed in the United Kingdom prior to the implementation of their liberalized Abortion Laws in the mid 1960s. A therapeutic abortion service to the Malaysian female was, therefore, only available on grounds of organic medical or psychiatric disease which constituted a threat to the mother’s life or health.
The term miscarriage is not defined in the Penal Code. In the case of In Re Malayara Seethu AIR 1955 Mys 27, the court referred to Modi’s Medical Jurisprudence on the meaning of miscarriage and other related terms. To quote Modi:
“Legally miscarriage means the premature expulsion of the product of conception, an ovum or a fetus, from the uterus, at any period before the full term is reached. Medically three distinct terms, viz. abortion, miscarriage and premature labor, are used to denote the expulsion of a fetus at different stages of gestation. Thus the term abortion is used only when an ovum is expelled within the first three months of pregnancy, before the placenta is formed. Miscarriage is used when a fetus is expelled from the fourth to the seventh month if gestation, before it is viable, while premature labor is the delivery of a viable child possibly capable of being reared, before it has become fully mature.”
The law on abortion prior to the amendment was as follows:
Sec. 312 – Whoever voluntarily cause a woman with child to miscarry shall, if such miscarriage be not caused in good faith for the purpose of saving the life of the woman, be punished with imprisonment for a term which may extend to three years, or with fine, or with both; and if the woman be quick with child, shall be punished with imprisonment for a term which may extend to seven years, and also be liable for a fine.
Sec. 313 – Whoever commits the offense defined in Section 312, without the consent of the woman, whether the woman is quick with child or not, shall be punished with imprisonment for life, or with imprisonment for a term which may extend to ten years, and shall be liable to a fine.
Sec. 314 – Whoever with intent to cause the miscarriage of a woman with child does any act which causes the death of such woman shall be punished with imprisonment for a term which may extend to ten years, and shall also be liable to fine, and if the act is done without the consent of the woman, shall be punished either with imprisonment for life, or with the punishment above mentioned.
Sec. 315 – Whoever before the birth of any child does any act with the intention and thereby preventing the child from being born alive, or causing it to die after its birth shall, if such act be not caused in good faith for the purpose of saving the life of the mother, be punished with imprisonment for a term which may extend to ten years or with fine or with both.
Sec. 316 – Whoever does any act under such circumstances that if he hereby caused death he would be guilty of culpable homicide and does by such act cause the death of quick unborn child shall be punished with imprisonment for a term which may extend to ten years and shall be liable to fine.
A Review of Abortion
performance of a therapeutic abortion on ‘social’ or ‘family planning’ grounds
was therefore not legally permissible in
The spectrum of personnel engaged in providing an illegal induced abortion service in the Malaysian private sector ranges from the well qualified and experienced gynecologist to a whole range of other personnel, i.e. general practitioners, nurse, midwife, hospital assistant, bidan (traditional midwife), bomoh (traditional Malay medicine man), sinseh (traditional Chinese medicine man) and untrained persons. The physical environment, methodology and instrumentation that have been utilized in such an abortion service have displayed a wide spectrum – from asepsis to varying degrees of sepsis; from skilled professionalism to varying degrees of unskilled; from complete evacuation of the products of conception to varying degree of completeness; from no residual maternal morbidity to varying degrees of maternal morbidity; and from no morbidity to significant maternal mortality.
As the abortion law then stood, abortions were only permitted on an extremely narrow ground – a pregnancy can only be terminated legally for the purpose of saving the life of the woman.
It has been the experience of most countries that a restrictive abortion law is unenforceable and discriminatory because it can be, and is, circumvented by those with adequate social and financial resources, which gives them access to psychiatrists, physicians and gynecologists.
Ad-Hoc Committee’s Recommendation
In 1986, an Ad-Hoc Committee on Abortion was appointed by the Council of the MMA to consider the need for reform of the abortion laws as it then was, in terms of widening the medical or therapeutic indication or abortion as opposed to socio-economic indications. The committee, which consisted of members from the Obstetrical and Gynecological Society of Malaysia, Bar Council, National Council of Women’s Organizations, Association of Women Lawyers and the National Population and Family Development Board, recommended that the penal code relating to abortion be amended to include the following indications for termination of pregnancy:
. when the physical or mental health of the woman is at risk
. when a pregnancy results from rape or incest.
It also recommended that in pursuance of the above, section 312 of the Penal Code be amended to read as follows:
“Whoever voluntarily cause a woman with child to miscarry shall, if such miscarriage be not caused in good faith for the purpose of saving the life of the woman or where the pregnancy is the result of rape or incest or where there is a reasonable risk of gross fetal abnormality, be punished with imprisonment for a term which may extend to seven years or with fine, or with both and if the woman be quick with child, shall be punished with imprisonment for a term which may extend to seven years, and also be liable to fine.”
The Abortion Laws in
Code (Amendment) Act 1989 (A727) effected changes in the law relating to
abortion. The amendments came into force on
Following the coming into force of the amending statute, the words “if such miscarriage be not caused in good faith for the purpose of saving the life of the woman” have been deleted from the section. Instead, an exception in different terms has been introduced, which exception provides that it will not be an offence if:
. a medical practitioner registered under the Medical Act 1971 undertakes the procedure, and
. such practitioner is of the opinion, formed in good faith, that the continuance of the pregnancy would involve risk to the life of the pregnant woman or injury to the mental or physical health of the pregnant woman greater than if the pregnancy were terminated.
The class of persons who may lawfully undertake an abortion has been restricted by the amendments to registered medical practitioners. Further, the strict requirements involved in the phrase ‘saving the life of the mother’ have given way to more relaxed conditions involving weighing of the reasons for and against continuing a pregnancy. The amendments implicitly require a doctor to exercise clinical judgment in deciding whether or not to terminate a pregnancy.
There is an exception to section 312 which states: “This section does not extend to a medical practitioner registered under the Medical Act 1971 who terminates the pregnancy of a woman if such a medical practitioner is of the opinion, formed in good faith, that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or injury to the mental or physical health of the pregnant woman, greater than if the pregnancy were terminated.” Section 313 covers miscarriages without the woman’s consent and Section 314 covers death caused by intent to cause miscarriage. There seems to be ambiguity because the exception clause does not cover Sections 313 and 314. Thus a medical practitioner may not be at fault for causing miscarriage but if the woman dies, he would be guilty of a criminal offence.
The Need to Legalize Abortion
Making abortion legal is an essential prerequisite to making it safe. In this respect, changing the law does matter and assertions to the contrary are ill conceived and unsupported in practice. Although in many countries trends towards safer abortions have often occurred prior to or in the absence of changes to the law, legal changes need to take place if safety is to be sustained for all women.
not only a question of safe medical procedures being used by individual
providers. It is also about removing the risk of exposure and the fear of
imprisonment and other punitive measures for both women and providers, even
where illegal abortion is tolerated. Health professionals providing safe but
clandestine abortion in urban
Safety is also about making sure that abortions will not be carried out by clandestine and unskilled providers who operate in situations that endanger women’s lives, even if they have the best of intentions. A woman has little or no recourse when abortion is illegal, even if she is seriously injured, badly treated, refused pain relief, sent home in a poor condition, charged a large amount of money or suffers any other form of negligence or malpractice. Continuing pregnancies following attempts at self-induced abortion are not uncommon and women may need follow-up care for other reasons, but they may be impossible to contact because they have given a false address.
Good laws and policies on abortion, in addition to being legal instruments, are a sign of public acceptance of fertility control and of women’s need for abortion. They signify an acceptance of the limitations of contraception and contraceptive use and of women’s right to decide the number and spacing of their children. They indicate a public health awareness of the costs of dangerous abortions, not only to women but also to their existing children, partners and families, and to health services and society as well.
Changing Laws and Policies
To make abortions safe, restrictive laws need to be amended, annulled or replaced; traditional and, in some cases, religious laws may also require attention when legal change is being contemplated. Countries have taken three main routes to this end: liberalizing the existing law within the penal or criminal code; partially or fully legalizing abortion through a positive law or court ruling; and decriminalizing abortion by taking it out of the law altogether8.
mortality and morbidity tend to be highest in countries where abortion laws are
most restrictive. Many such laws originate from colonial times and are no longer
operative in the countries that drew them up. Restrictive laws allow abortion
only when a woman can be seen as a victim of circumstances, i.e. in a medical
emergency or cases of fetal abnormality or following rape or incest. Yet the
great majority of women need abortions for family planning reasons and on
economic and social grounds. The least fundamental form of abortion law reform
is to add limited grounds for abortion to an already restrictive criminal law.
In Ghana, a 1960 law allowed abortion only to save a woman’s life, while a 1985
amendment allowed abortion to protect a woman’s physical or mental health as
well as on judicial and fetal impairment grounds. However, in 1995 unsafe
abortions and high abortion mortality were still common in
grounds for abortion to achieve partial legalization may be added to an existing
law. This is what happened in
However, the treatment for the termination of a pregnancy shall not be carried out:
. if the pregnancy is of more than twenty-four weeks’ duration unless such treatment is immediately necessary to save the life of the pregnant woman or to prevent grave permanent injury to her physical or mental health; or
. if the pregnancy is of more than sixteen weeks’ duration but less than twenty-four weeks’ duration unless the treatment is carried out by a registered medical practitioner who:
- is in possession of such surgical or obstetric qualifications as may be prescribed; or
- has acquired special skill in such treatment either in practice or by virtue of holding an appointment in a Government hospital or in an approved institution over such period as may be prescribed.
In the case of a pregnancy of less than twenty-four weeks’ duration, there is no need for medical justification to enable a doctor to procure an abortion provided he does so at the request of the patient and with her written consent.
order not to allow
What are the precautions that a doctor should observe before causing an abortion in order not to run afoul of the law?
Mehta offers the following advice:
“It is advisable that a doctor should observe the following procedure before undertaking an abortion for the purpose of saving the life of a woman. He should obtain in writing the consent of the woman and her husband. In the event of the husband refusing to give such consent, it is submitted that it would be lawful for a medical practitioner to perform the abortion provided it is done in good faith and for the purpose of saving the life of the woman and she gives her consent. Further, it is advisable that a second professional opinion as to its necessity for the purpose of saving the life of the woman, preferably a senior practitioner or a specialist, should be obtained.
These safeguard against a subsequent false charge of illegal abortion. In the event of the specialist or the senior practitioner taking a contrary view, it is nevertheless open to the medical practitioner to perform an operation for abortion if he honestly believes it to be necessary for saving the life of the woman.
He should, however, make a contemporaneous note in his records stating briefly the reasons why he considers the abortion necessary.”
Quality of Care
abortion services out into the open is a precondition for ensuring quality of
care, accessibility, availability and affordability especially for the poorest
woman. This encourages health professionals to provide a defensible service. In
Other ways to monitor and ensure quality of care include the following: oversight by an independent national advisory body, decisions as to whether or not the procedure will be covered by national health insurance, the standards that approved institutions must meet, regulation of fees for services and requirements for record keeping and the collection of data. Where deaths from unsafe abortions were previously high, the collection of baseline data and regular audit of all reported abortion-related deaths, as part of broader maternal mortality audits will reveal continuing risks, allowing discussion and action to reduce these.
Guidelines for health service professionals are valuable for ensuring equity of access and quality of care. The UK Royal College of O&G has prepared guidelines for organization of services, information for women, pre-abortion assessment, abortion procedures, management of complications and after-care10.
Six primary interventions exist to reduce the burden of mortality and morbidity from an unsafe abortion.
1. Establish Unconstrained Availability of Family Planning
There is compelling evidence that realistic availability of family planning reduces abortion rates, although it can never eliminate the role of induced abortion in fertility regulation11. To limit family size in the absence of contraception, many abortions will be requested.
2. Improve Post-Abortion Care
Women suffering from incomplete abortion deserve humane, compassionate treatment and realistic contraceptive advice. The opportunity to counsel women on contraceptive advice post-abortion continues to be missed in the great majority of developing countries. When contraceptive advice and counseling is given, there is good uptake12.
Table II: Improved contraceptive use
following the introduction of post-abortion care12
Percent contraceptive use
Percent contraceptive use
3. Full Application of Existing Abortion Laws
4. Reform the Abortion Law
This has been discussed previously in this paper.
5. Disseminate the Manual Vacuum Aspiration Method
Manual vacuum aspiration was introduced in 197213. This method uses a hand held plastic syringe and a flexible Karman cannula and its safety is well documented13. High quality MVA equipment costs as little as USD5 and it can be reused many times. Manual vacuum aspiration can be used to induce an abortion up to 10-12 weeks menstrual age, for uterine biopsy and to treat incomplete abortions.
6. Capitalize on the Benefits of Misoprostol
Misoprostol has many gynecological uses although it is sold for the treatment of gastric and duodenal ulcers14. Where women have access to this drug, the number of septic abortions coming to hospitals is falling.
As is well known, all procedures carry a risk. A patient must be adequately counseled as to all risks with the procedure and consent obtained. It is felt that if death then occurs, it should not be a criminal offence but rather covered under tort. If a patient dies after cardiac surgery, would the surgeon be handcuffed and dragged to court? No, as there is no penal code section covering deaths after cardiac surgery.
We should strive to achieve the following:
. Hold the principle that we are in support of revising national laws and policies that compromise women’s reproductive health and options by restricting their access to services, placing them at risk of domestic violence or constraining their economic opportunities. For example, spousal consent is not necessary for sterilization.
. Support the expansion of expanding training programs and curricula to cover the full range of technical and interpersonal skills necessary to provide high quality care to women being treated for post abortion complications.
. Support the structuring of health service delivery systems that place family regulation and limitation programs at a higher level than is found presently.
. Support conducting community education to ensure that women know what services are legally available and where they are offered within the framework of ethical practice.
. Support research activities in all aspects of women’s health.
. Urge nations to allocate the human and financial resources to carry out these activities.
Much can be done despite the difficulties of changing national abortion laws. Women’s health groups and other advocates, parliamentarians and health professionals can work together to support the right of women not to die from unsafe abortions and to ensure that they receive treatment for complications. In countries where the letter of the law is not a primary obstacle, they can also campaign for a choice of safe abortion methods, improvements in regulations governing the registration of providers and facilities and for better training of providers. Additionally they can monitor accessibility, affordability and quality of care in these services.
Abortion law reform is a necessary condition for making abortion safe though it is not sufficient in itself. Women remain vulnerable where safe abortion is not legally sanctioned because quality of care cannot be assured, abuses cannot be challenged and both women and providers remain at risk of prosecution, blackmail, social and professional stigma. In the long run, abortion needs to be decriminalized in order for it to be made safe.
Although law, policy and women’s rights are central to this issue, making abortion safe is above all a public health responsibility of governments. Reducing maternal mortality by making abortions safe is also an important part of the international commitment made in Cairo in 1994 at the UN International Conference on Population and Development (ICPD) and reaffirmed at the Cairo+5 meeting in 1999. We owe this to the women who take on this dangerous journey during a pregnancy till delivery. If a woman who has a pregnancy that affects her health desires that she not continue with it, the doctor who treats her should be able to perform any required procedure without being fearful of running afoul of the law.
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