Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model

TLDR

Previous estimates of unsafe abortions were published in 1995, 2003, and 2008, but new methods are needed due to widespread medical abortion, misoprostol use outside formal health systems, and other safety factors. The study aimed to estimate global, regional, and subregional distributions of abortions by safety categories using a Bayesian hierarchical model. The authors applied a Bayesian hierarchical model incorporating empirical data on methods, providers, settings, and safety factors, and classified abortions into safe, less safe, and least safe categories per WHO definitions. Between 2010 and 2014, 55.7 million abortions occurred worldwide, with 54.9 % safe, 30.7 % less safe, and 14.4 % least safe, meaning 45.1 % were unsafe—most of which (97 %) occurred in developing countries and were more common in restrictive‑law settings, underscoring the need for expanded safe‑abortion access. Funding was provided by UNDP/UNFPA/UNICEF/WHO/World Bank, the Packard Foundation,.

Abstract

Global estimates of unsafe abortions have been produced for 1995, 2003, and 2008. However, reconceptualisation of the framework and methods for estimating abortion safety is needed owing to the increased availability of simple methods for safe abortion (eg, medical abortion), the increasingly widespread use of misoprostol outside formal health systems in contexts where abortion is legally restricted, and the need to account for the multiple factors that affect abortion safety.We used all available empirical data on abortion methods, providers, and settings, and factors affecting safety as covariates within a Bayesian hierarchical model to estimate the global, regional, and subregional distributions of abortion by safety categories. We used a three-tiered categorisation based on the WHO definition of unsafe abortion and WHO guidelines on safe abortion to categorise abortions as safe or unsafe and to further divide unsafe abortions into two categories of less safe and least safe.Of the 55· 7 million abortions that occurred worldwide each year between 2010-14, we estimated that 30·6 million (54·9%, 90% uncertainty interval 49·9-59·4) were safe, 17·1 million (30·7%, 25·5-35·6) were less safe, and 8·0 million (14·4%, 11·5-18·1) were least safe. Thus, 25·1 million (45·1%, 40·6-50·1) abortions each year between 2010 and 2014 were unsafe, with 24·3 million (97%) of these in developing countries. The proportion of unsafe abortions was significantly higher in developing countries than developed countries (49·5% vs 12·5%). When grouped by the legal status of abortion, the proportion of unsafe abortions was significantly higher in countries with highly restrictive abortion laws than in those with less restrictive laws.Increased efforts are needed, especially in developing countries, to ensure access to safe abortion. The paucity of empirical data is a limitation of these findings. Improved in-country data for health services and innovative research to address these gaps are needed to improve future estimates.UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction; David and Lucile Packard Foundation; UK Aid from the UK Government; Dutch Ministry of Foreign Affairs; Norwegian Agency for Development Cooperation.