Novel approaches to estimating abortion incidence.

BACKGROUND: In countries where abortion is legally restricted or clandestine, estimates of abortion incidence are needed in order to bring attention to the reality of this practice. Innovations in methods for estimating stigmatized behaviors, coupled with changes in the conditions under which women obtain abortions, prompt us to review new approaches to estimating abortion incidence and propose innovations in this field. METHODS: We discuss five approaches for yielding accurate estimates in countries with restrictive abortion laws. These include two prevailing approaches in the field (direct questioning of women about their abortions and the Abortion Incidence Complications Method (AICM)), one that has begun to be in use in recent years (the List Experiment) and two that are newly proposed by the authors (the Confidante Approach and a modification of the AICM). We discuss assumptions, strengths and weaknesses of each approach. Finally, we suggest strategies for assessing the validity of the findings in the absence of a gold standard. RESULTS: Though direct questioning has consistently been shown to miss many abortions, reporting can potentially be improved by normalizing or reframing the experience of abortion. The AICM has had the advantage of not relying on women's reports about their abortions; however as self-induced abortion becomes more common, this strength becomes a weakness. The modified AICM, which uses women's abortion reports to estimate the proportion of abortions that lead to treated complications, improves our chances of capturing self-induced abortions. The List Experiment preserves the woman's anonymity (not just her confidentiality), but it can be cognitively challenging and the potential to make subgroup estimates is extremely limited. The Confidante Approach entails asking survey respondents about abortions among women who confide in them, rather than their own abortions. An adjustment factor can be applied to estimate the incidence of confidantes' abortions that are unknown to respondents. This approach relies on the assumption that women know and will report whether their confidantes had an abortion. In the absence of a gold standard measure of abortion incidence, four strategies can be employed to compare and assess these approaches: (a) comparing the level of underreporting across methods susceptible to underreporting but not to overreporting, (2) validating components of abortion estimates against an objective measure, (3) testing whether these strategies accurately estimate other sensitive behaviors for which a gold standard exists, and 4) sensitivity analyses. Ultimately, it might be appropriate to employ more than one methodology when measuring abortion incidence.

Pregnancies, abortions, and pregnancy intentions: a protocol for modeling and reporting global, regional and country estimates.

BACKGROUND: Estimates of pregnancies, abortions and pregnancy intentions can help assess how effectively women and couples are able to fulfil their childbearing aspirations. Abortion incidence estimates are also a necessary foundation for research on the safety of abortions performed and the consequences of unsafe abortion. Furthermore, periodic estimates of these indicators are needed to help inform policy and programmes. METHODS: We will develop a Bayesian hierarchical times series model which estimates levels and trends in pregnancy rates, abortion rates, and percentages of pregnancies and births unintended for each five-year period between 1990 and 2019. The model will be informed by data on abortion incidence and the percentage of births or pregnancies that were unintended. We will develop a data classification process to be applied to all available data. Model-based estimates and associated uncertainty will take account of data sparsity and quality. Our proposed approach will advance previous work in two key ways. First, we will estimate pregnancy and abortion rates simultaneously, and model the propensity to abort an unintended pregnancy, as opposed to modeling abortion rates directly as in prior work. Secondly, we will produce estimates that are reproducible at the country level by publishing the data inputs, data classification processes and source code. DISCUSSION: This protocol will form the basis for updated global, regional and national estimates of intended and unintended pregnancy rates, abortion rates, and the percent of unintended pregnancies ending in abortion, from 1990 to 2019.

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

BACKGROUND: 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. METHODS: 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. FINDINGS: Of the 55·â€ˆ7 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. INTERPRETATION: 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. FUNDING: 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.

Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends.

BACKGROUND: Information about the incidence of induced abortion is needed to motivate and inform efforts to help women avoid unintended pregnancies and to monitor progress toward that end. We estimate subregional, regional, and global levels and trends in abortion incidence for 1990 to 2014, and abortion rates in subgroups of women. We use the results to estimate the proportion of pregnancies that end in abortion and examine whether abortion rates vary in countries grouped by the legal status of abortion. METHODS: We requested abortion data from government agencies and compiled data from international sources and nationally representative studies. With data for 1069 country-years, we estimated incidence using a Bayesian hierarchical time series model whereby the overall abortion rate is a function of the modelled rates in subgroups of women of reproductive age defined by their marital status and contraceptive need and use, and the sizes of these subgroups. FINDINGS: We estimated that 35 abortions (90% uncertainty interval [UI] 33 to 44) occurred annually per 1000 women aged 15-44 years worldwide in 2010-14, which was 5 points less than 40 (39-48) in 1990-94 (90% UI for decline -11 to 0). Because of population growth, the annual number of abortions worldwide increased by 5.9 million (90% UI -1.3 to 15.4), from 50.4 million in 1990-94 (48.6 to 59.9) to 56.3 million (52.4 to 70.0) in 2010-14. In the developed world, the abortion rate declined 19 points (-26 to -14), from 46 (41 to 59) to 27 (24 to 37). In the developing world, we found a non-significant 2 point decline (90% UI -9 to 4) in the rate from 39 (37 to 47) to 37 (34 to 46). Some 25% (90% UI 23 to 29) of pregnancies ended in abortion in 2010-14. Globally, 73% (90% UI 59 to 82) of abortions were obtained by married women in 2010-14 compared with 27% (18 to 41) obtained by unmarried women. We did not observe an association between the abortion rates for 2010-14 and the grounds under which abortion is legally allowed. INTERPRETATION: Abortion rates have declined significantly since 1990 in the developed world but not in the developing world. Ensuring access to sexual and reproductive health care could help millions of women avoid unintended pregnancies and ensure access to safe abortion. FUNDING: UK Government, Dutch Ministry of Foreign Affairs, Norwegian Agency for Development Cooperation, The David and Lucile Packard Foundation, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Intended and unintended pregnancies worldwide in 2012 and recent trends.

Periodic estimation of the incidence of global unintended pregnancy can help demonstrate the need for and impact of family planning programs. We draw upon multiple sources of data to estimate pregnancy incidence by intention status and outcome at worldwide, regional, and subregional levels in 2012 and to assess recent trends using previously published estimates for 2008 and 1995. We find that 213 million pregnancies occurred in 2012, up slightly from 211 million in 2008. The global pregnancy rate decreased only slightly from 2008 to 2012, after declining substantially between 1995 and 2008. Eighty-five million pregnancies, representing 40 percent of all pregnancies, were unintended in 2012. Of these, 50 percent ended in abortion, 13 percent ended in miscarriage, and 38 percent resulted in an unplanned birth. The unintended pregnancy rate continued to decline in Africa and in the Latin America and Caribbean region. If the aims of the London Summit on Family Planning are carried out, the incidence of unwanted and mistimed pregnancies should decline in the coming years.

Induced abortion: incidence and trends worldwide from 1995 to 2008.

BACKGROUND: Data of abortion incidence and trends are needed to monitor progress toward improvement of maternal health and access to family planning. To date, estimates of safe and unsafe abortion worldwide have only been made for 1995 and 2003. METHODS: We used the standard WHO definition of unsafe abortions. Safe abortion estimates were based largely on official statistics and nationally representative surveys. Unsafe abortion estimates were based primarily on information from published studies, hospital records, and surveys of women. We used additional sources and systematic approaches to make corrections and projections as needed where data were misreported, incomplete, or from earlier years. We assessed trends in abortion incidence using rates developed for 1995, 2003, and 2008 with the same methodology. We used linear regression models to explore the association of the legal status of abortion with the abortion rate across subregions of the world in 2008. FINDINGS: The global abortion rate was stable between 2003 and 2008, with rates of 29 and 28 abortions per 1000 women aged 15-44 years, respectively, following a period of decline from 35 abortions per 1000 women in 1995. The average annual percent change in the rate was nearly 2·4% between 1995 and 2003 and 0·3% between 2003 and 2008. Worldwide, 49% of abortions were unsafe in 2008, compared to 44% in 1995. About one in five pregnancies ended in abortion in 2008. The abortion rate was lower in subregions where more women live under liberal abortion laws (p<0·05). INTERPRETATION: The substantial decline in the abortion rate observed earlier has stalled, and the proportion of all abortions that are unsafe has increased. Restrictive abortion laws are not associated with lower abortion rates. Measures to reduce the incidence of unintended pregnancy and unsafe abortion, including investments in family planning services and safe abortion care, are crucial steps toward achieving the Millennium Development Goals. FUNDING: UK Department for International Development, Dutch Ministry of Foreign Affairs, and John D and Catherine T MacArthur Foundation.

Identifying and prioritizing evidence needs in self-care interventions for sexual and reproductive health.

Background: Self-care as an extension of health care systems can increase access to care. The development of programs and generation of evidence to support self-care in sexual and reproductive health (SRH) is a relatively nascent field. We undertook a study to identify and prioritize evidence gaps for SRH self-care. Methods: We used the CHNRI methodology and administered two online surveys to stakeholders affiliated with major self-care networks. The first survey was used to identify evidence gaps, and the second to prioritize them using predetermined criteria. Results: We received 51 responses to the first survey and 36 responses to the second. Many evidence gaps focused on awareness of and demand for self-care options and best mechanisms for supporting users of self-care with information, counseling and linkages to care. Conclusion: A priority area of work ahead should be determining which aspects of the learning agenda reflect gaps in evidence and which reflect a need to effectively synthesize and disseminate existing evidence.

Scoping review of research on self-managed medication abortion in low-income and middle-income countries.

BACKGROUND: We undertook a scoping review of recent studies on self-managed medical abortion (MA) or abortion where some or all of the process is led independently by the person having the abortion, in low-income and middle-income countries (LMICs) to uncover evidence gaps and help stakeholders leverage existing evidence. METHODS: We searched five bibliographic databases for all articles published on MA between 2007 and July 2020 in LMICs. The search yielded 1294 articles. We identified 107 articles in which one or more of the three WHO-defined subtasks for MA was self-led outside of a clinic setting, and use of drugs that are part of safe, evidence-based regimens was related to the study exposure or outcome. We classified these studies by subject area, study design, country, legal context, gestational age and other categories. RESULTS: The 107 studies covered research in 44 countries, of which 18 have liberal abortion laws. Seventy- four articles reported on quantitative research methods, of which 14 were randomised controlled trials. Fifty-two studies focused on MA in the first trimester. Sixty-two focused on WHO subtask two (drug administration) and 32 focused on subtask three (assessing and managing abortion completion). We found little research on self-management of the entire MA process, innovative approaches to supporting self-managed MA or the needs of underserved populations. CONCLUSION: We recommend syntheses of evidence on safety and efficacy of self-managed MA and preferences of people undergoing self-managed MA. We also encourage new research on topics including self-management of the entire process, the needs and experiences of underserved populations and innovative approaches to supporting people undertaking self-managed MA. The time is opportune for amplifying and expanding evidence to inform programmes and policies on self-care.

An Application of the Confidante Method to Estimate Induced Abortion Incidence in Java, Indonesia.

CONTEXT: Induced abortion is legally restricted and highly stigmatized in Indonesia, and is thus extremely difficult to measure. Indirect methods leveraging women's social networks, such as the Confidante Method, have shown promise in estimating hidden behaviors, including abortion, in similar settings. METHODS: A community-based survey was conducted among 8,696 women aged 15-49 in Java, Indonesia, in November 2018-January 2019. Data were collected via in-person interviews with respondents about their own abortions and those of up to three of their closest confidantes. One-year induced abortion incidence rates per 1,000 women were estimated using a direct-report approach and the Confidante Method. RESULTS: The direct-report abortion rate was 3.4 per 1,000 women in 2018, compared with the Confidante Method rate of 11.3 per 1,000. Among the confidantes of women who reported an abortion in the past five years, the abortion rate was 42.0 per 1,000. Half of the women reported that they had no confidantes with whom they shared private information. Among women reporting an abortion and at least one confidante, 58% had disclosed their abortion to their confidante, indicating that substantial transmission bias was present. CONCLUSIONS: The Confidante Method relies on several assumptions that did not hold in this study. Although the method performed better than the direct-report approach, it underestimated the incidence of abortion in Java. More research is needed to understand how abortion-related information is shared within social networks and to assess the appropriateness of applying the Confidante Method to estimate abortion in a given context.

RESUMEN Contexto: El aborto inducido está restringido legalmente y sumamente estigmatizado en Indonesia y, por lo tanto, es extremadamente difícil de medir. Los métodos indirectos que aprovechan las redes sociales de mujeres, como el método basado en confidentes, han demostrado ser promisorios para estimar comportamientos que se ocultan, incluido el aborto, en entornos similares. Métodos: Entre noviembre de 2018 y enero de 2019, se llevó a cabo una encuesta basada en la comunidad entre 8,696 mujeres en edades de 15 a 49 años en Java, Indonesia. Se recolectaron datos a través de entrevistas presenciales con personas sobre sus propios abortos y los de hasta tres de sus confidentes más cercanas. Se estimaron tasas anuales de incidencia de aborto inducido por 1,000 mujeres mediante el uso del enfoque de informe directo y del método basado en confidentes. Resultados: La tasa de aborto por informe directo fue de 3.4 por 1,000 mujeres en 2018, en comparación con la tasa del método basado en confidentes de 11.3 por 1,000. Entre las personas confidentes de mujeres que reportaron haber tenido un aborto en los últimos cinco años, la tasa de aborto fue de 42.0 por 1,000. La mitad de las mujeres reportaron que no tenían confidentes con quienes compartir su información privada. Entre las mujeres que reportaron haber tenido un aborto y tener al menos una persona confidente, el 58% habían revelado su aborto a su confidente, lo que indica que hubo un importante sesgo de transmisión. Conclusiones: El método basado en confidentes depende de varias suposiciones que no fueron aplicables en este estudio. Aunque el método funcionó mejor que el enfoque de informe directo, subestimó la incidencia del aborto en Java. Es necesario realizar más investigación para comprender la forma en que la información relacionada con el aborto se comparte dentro de las redes sociales, así como para determinar qué tan apropiado es aplicar el método basado en confidentes para estimar la incidencia del aborto en un contexto determinado.

RÉSUMÉ Contexte: L'avortement provoqué est limité par la loi et fait l'objet d'une forte stigmatisation en Indonésie. Il est par conséquent extrêmement difficile d'en mesurer l'incidence. Les méthodes indirectes tirant parti des réseaux sociaux des femmes, comme celle de la « confidente ¼, se sont révélées prometteuses dans l'estimation de comportements cachés, notamment l'avortement, dans des contextes comparables. Méthodes: Une enquête communautaire a été menée auprès de 8 696 femmes âgées de 15 à 49 ans à Java (Indonésie) entre novembre 2018 et janvier 2019. Les données ont été collectées dans le cadre d'entretiens personnels avec les répondantes, concernant leurs propres avortements et ceux d'un maximum de trois de leurs confidentes les plus proches. Les taux d'incidence de l'avortement provoqué d'une année pour 1 000 femmes ont été estimés selon une approche de déclaration directe et par la méthode de la confidente. Résultats: Le taux d'avortement estimé par déclaration directe s'est avéré de 3,4 pour 1 000 femmes en 2018, par rapport à 11,3 pour 1 000 selon la méthode de la confidente. Parmi les confidentes des femmes ayant déclaré un avortement durant les cinq dernières années, le taux s'élevait à 42,0 pour 1 000. La moitié des femmes ont déclaré ne pas avoir de confidentes avec lesquelles elles partageaient une information privée. Parmi les femmes déclarant un avortement et au moins une confidente, 58% avaient divulgué leur avortement à leur confidente, indiquant un biais de transmission considérable. Conclusions: La méthode de la confidente repose sur plusieurs hypothèses non confirmées dans cette étude. Bien qu'ayant produit de meilleurs résultats que l'approche par déclaration directe, elle sous-estime l'incidence de l'avortement à Java. Il convient d'approfondir la recherche pour comprendre les modalités du partage de l'information relative à l'avortement au sein des réseaux sociaux et pour évaluer la pertinence du recours à la méthode de la confidente pour estimer l'incidence de l'avortement dans un contexte donné.

Estimating the Incidence of Induced Abortion in Java, Indonesia, 2018.

CONTEXT: In Indonesia, maternal mortality is high and abortion is restricted. Reliable information on induced abortion is needed; however, the difficulty of measuring abortion in settings where it is legally restricted and highly stigmatized calls for innovation in approaches to measuring abortion incidence. METHODS: The data were from three original surveys conducted in Java among health facilities, knowledgeable informants and women aged 15-49, fielded in April 2018-January 2019. Two methods were used to estimate the one-year induced abortion incidence rate in Java: the standard Abortion Incidence Complications Method (AICM) and a modified AICM. Each method was evaluated on the basis of data quality, and what is known about sexual and reproductive health indicators related to abortion rates, to determine which performed best in measuring abortion incidence in Java. RESULTS: Estimates of complications resulting from induced abortion from knowledgeable informants and the women differed substantially. The modified AICM produced an estimate of 42.5 abortions per 1,000 women aged 15-49, while the standard AICM estimate was lower (25.8 per 1,000). A comparison of the distribution of abortion methods used revealed that knowledgeable informants believed abortion was less safe than indicated by women's reports of their own experiences. Therefore, the standard AICM likely underestimates abortion. CONCLUSIONS: The modified AICM performed better than the standard AICM and indicates that abortion is common in Java. Increased access to contraceptives and high-quality postabortion care is needed. Future research should investigate the safety of abortion, especially with respect to self-managed abortion.

RESUMEN Contexto: La mortalidad materna en Indonesia es alta y el aborto está restringido. Se necesita información confiable sobre el aborto inducido; sin embargo, la dificultad de medir el aborto en entornos donde está restringido legalmente y es fuertemente estigmatizado, requiere esfuerzos de innovación en los enfoques para medir la incidencia del aborto. Métodos: Los datos se obtuvieron de tres encuestas originales realizadas en Java entre instituciones de salud, informantes conocedores del tema y mujeres en edades de 15 a 49 años y que fueron aplicadas entre abril de 2018 y enero de 2019. Se usaron dos métodos para estimar la tasa de incidencia de aborto inducido en un año en Java: el método estándar de estimación de aborto por complicaciones (AICM, por sus siglas en inglés) y el AICM modificado. Cada método se evaluó con base en la calidad de los datos y en lo que se sabe sobre indicadores de salud sexual y reproductiva relacionados con las tasas de aborto, para determinar cuál método se desempeñó mejor en la medición de la incidencia de aborto en Java. Resultados: Las estimaciones de complicaciones derivadas del aborto inducido según informantes conocedores del tema y según las mujeres, difirieron sustancialmente. El AICM modificado produjo una estimación de 42.5 abortos por 1,000 mujeres en edades de 15 a 49 años, mientras que la estimación del AICM estándar fue más baja (25.8 por 1,000). Una comparación de la distribución de los métodos de aborto usados reveló que los informantes conocedores creían que el aborto era menos seguro que lo indicado en los informes de las mujeres basados en sus propias experiencias. Por lo tanto, es probable que el método AICM estándar subestime la incidencia del aborto. Conclusiones: El método AICM modificado funcionó mejor que el AICM estándar e indica que el aborto es una práctica común en Java. Son necesarios un mayor acceso a los anticonceptivos y a una atención postaborto de alta calidad. Las futuras investigaciones deben investigar la seguridad del aborto, especialmente en relación con el aborto autoadministrado.

RÉSUMÉ Contexte: En Indonésie, la mortalité maternelle est élevée et l'avortement est limité par la loi. Il existe un besoin d'information fiable concernant l'avortement provoqué. La difficulté de mesurer l'avortement dans les contextes où il est strictement limité et fortement stigmatisé demande cependant des approches innovantes. Méthodes: Les données proviennent de trois enquêtes initiales menées à Java auprès de structures de santé, de sources bien informées et de femmes âgées de 15 à 49 ans, entre avril 2018 et janvier 2019. Le taux d'incidence de l'avortement provoqué à l'échelle d'une année à Java a été estimé selon deux méthodes: la méthode AICM standard d'évaluation de l'incidence de l'avortement en fonction des complications traitées et une méthode AICM modifiée. Chaque méthode a été évaluée en fonction de la qualité des données et de l'information connue sur les indicateurs de santé sexuelle et reproductive relatifs aux taux d'avortement, afin de déterminer celle qui avait le mieux mesuré l'incidence de l'avortement à Java. Résultats: Les estimations des complications résultant de l'avortement provoqué obtenues des sources informées et des femmes consultées se sont avérées nettement différentes. La méthode AICM modifiée a produit une estimation de 42,5 avortements pour 1 000 femmes âgées de 15 à 49 ans, tandis que la méthode AICM standard produisait une estimation inférieure (25,8 pour 1 000). En comparant la distribution des méthodes d'avortement pratiquées, on a constaté que les sources informées estimaient l'avortement moins sùr que ne l'indiquaient les déclarations des femmes concernant leur propre expérience. Il est dès lors probable que la méthode AICM standard sous-estime l'avortement. Conclusions: La méthode AICM modifiée, plus efficace que la méthode standard, fait état d'une pratique courante de l'avortement à Java. Un meilleur accès à la contraception et à des soins après avortement de qualité est nécessaire. La recherche future devrait se pencher sur la sécurité de l'avortement, en ce qui concerne en particulier les interventions autogérées.

Trends in the method and gestational age of abortion in high-income countries.

BACKGROUND: Examining the distribution of abortions by method of abortion and gestational age at time of termination provides insight about the options women may have to terminate their pregnancies. Comparing these distributions across countries and over time is an important step toward understanding the factors that can drive these distributions, including regulations and practices related to the provision of abortion services, and women's preferences and needs. METHODS: We sought official statistics on gestational age and method of abortion for all high-income countries with liberal abortion laws. For the 24 high-income countries with available data, we calculated percentage distributions of abortions by gestational age of pregnancy and method of abortion for 2017 or the most recent year for which data were available, and assessed trends in the preceding 10 years whenever possible. RESULTS: Medication (or medical) abortion accounts for at least half of all abortions in the majority of countries. In the majority of countries over 90% of all abortions were completed before 13 weeks, and more than two-thirds of abortions occurred before the first 9 weeks of gestation. Over the past 10 years there has been an increase in both the proportion of abortions that were medication abortions and the proportion that were obtained before 9 weeks gestation. CONCLUSIONS: These findings highlight changes in abortion provision in the past decade. More research is needed to understand whether the observed distributions are a function of women's preferences or of barriers to the timing and type of care they would prefer.

Induced abortion: estimated rates and trends worldwide.

BACKGROUND: Information on incidence of induced abortion is crucial for identifying policy and programmatic needs aimed at reducing unintended pregnancy. Because unsafe abortion is a cause of maternal morbidity and mortality, measures of its incidence are also important for monitoring progress towards Millennium Development Goal 5. We present new worldwide estimates of abortion rates and trends and discuss their implications for policies and programmes to reduce unintended pregnancy and unsafe abortion and to increase access to safe abortion. METHODS: The worldwide and regional incidences of safe abortions in 2003 were calculated by use of reports from official national reporting systems, nationally representative surveys, and published studies. Unsafe abortion rates in 2003 were estimated from hospital data, surveys, and other published studies. Demographic techniques were applied to estimate numbers of abortions and to calculate rates and ratios for 2003. UN estimates of female populations and livebirths were the source for denominators for rates and ratios, respectively. Regions are defined according to UN classifications. Trends in abortion rates and incidences between 1995 and 2003 are presented. FINDINGS: An estimated 42 million abortions were induced in 2003, compared with 46 million in 1995. The induced abortion rate in 2003 was 29 per 1000 women aged 15-44 years, down from 35 in 1995. Abortion rates were lowest in western Europe (12 per 1000 women). Rates were 17 per 1000 women in northern Europe, 18 per 1000 women in southern Europe, and 21 per 1000 women in northern America (USA and Canada). In 2003, 48% of all abortions worldwide were unsafe, and more than 97% of all unsafe abortions were in developing countries. There were 31 abortions for every 100 livebirths worldwide in 2003, and this ratio was highest in eastern Europe (105 for every 100 livebirths). INTERPRETATION: Overall abortion rates are similar in the developing and developed world, but unsafe abortion is concentrated in developing countries. Ensuring that the need for contraception is met and that all abortions are safe will reduce maternal mortality substantially and protect maternal health.

Global, regional, and subregional trends in unintended pregnancy and its outcomes from 1990 to 2014: estimates from a Bayesian hierarchical model.

BACKGROUND: Estimates of pregnancy incidence by intention status and outcome indicate how effectively women and couples are able to fulfil their childbearing aspirations, and can be used to monitor the impact of family-planning programmes. We estimate global, regional, and subregional pregnancy rates by intention status and outcome for 1990-2014. METHODS: We developed a Bayesian hierarchical time series model whereby the unintended pregnancy rate is a function of the distribution of women across subgroups defined by marital status and contraceptive need and use, and of the risk of unintended pregnancy in each subgroup. Data included numbers of births and of women estimated by the UN Population Division, recently published abortion incidence estimates, and findings from surveys of women on the percentage of births or pregnancies that were unintended. Some 298 datapoints on the intention status of births or pregnancies were obtained for 105 countries. FINDINGS: Worldwide, an estimated 44% (90% uncertainty interval [UI] 42-48) of pregnancies were unintended in 2010-14. The unintended pregnancy rate declined by 30% (90% UI 21-39) in developed regions, from 64 (59-81) per 1000 women aged 15-44 years in 1990-94 to 45 (42-56) in 2010-14. In developing regions, the unintended pregnancy rate fell 16% (90% UI 5-24), from 77 (74-88) per 1000 women aged 15-44 years to 65 (62-76). Whereas the decline in the unintended pregnancy rate in developed regions coincided with a declining abortion rate, the decline in developing regions coincided with a declining unintended birth rate. In 2010-14, 59% (90% UI 54-65) of unintended pregnancies ended in abortion in developed regions, as did 55% (52-60) of unintended pregnancies in developing regions. INTERPRETATION: The unintended pregnancy rate remains substantially higher in developing regions than in developed regions. Sexual and reproductive health services are needed to help women avoid unintended pregnancies, and to ensure healthy outcomes for those who do experience such pregnancies. FUNDING: Dutch Ministry of Foreign Affairs and UK Aid from the UK Government.

Legal abortion worldwide: incidence and recent trends.

CONTEXT: Information on abortion levels and trends can inform research and policies affecting maternal and reproductive health, but the incidence of legal abortion has not been assessed in nearly a decade. METHODS: Statistics on legal abortions in 2003 were compiled for 60 countries in which the procedure is broadly legal, and trends were assessed where possible. Data sources included published and unpublished reports from official national reporting systems, questionnaires sent to government agencies and nationally representative population surveys. The completeness of country estimates was assessed by officials involved in data collection and by in-country and regional experts. RESULTS: In recent years, more countries experienced a decline in legal abortion rates than an increase, among those for which statistics are complete and trend data are available. The most dramatic declines were in Eastern Europe and Central Asia, where rates remained among the highest in the world. The highest estimated levels were in Armenia, Azerbaijan and Georgia, where surveys indicate that women will have close to three abortions each, on average, in their lifetimes. The U.S. abortion rate dropped by 8% between 1996 and 2003, but remained higher than rates in many Northern and Western European countries. Rates increased in the Netherlands and New Zealand. The official abortion rate declined by 21% over seven years in China, which accounted for a third of the world's legal abortions in 1996. Trends in the abortion rate differed across age-groups in some countries. CONCLUSIONS: The abortion rate varies widely across the countries in which legal abortion is generally available and has declined in many countries since the mid-1990s.

Legal abortion worldwide: incidence and recent trends.

CONTEXT: Information on abortion levels and trends can inform research and policies affecting maternal and reproductive health, but the incidence of legal abortion has not been assessed in nearly a decade. METHODS: Statistics on legal abortions in 2003 were compiled for 60 countries in which the procedure is broadly legal, and trends were assessed where possible. Data sources included published and unpublished reports from official national reporting systems, questionnaires sent to government agencies and nationally representative population surveys. The completeness of country estimates was assessed by officials involved in data collection and by in-country and regional experts. RESULTS: In recent years, more countries experienced a decline in legal abortion rates than an increase, among those for which statistics are complete and trend data are available. The most dramatic declines were in Eastern Europe and Central Asia, where rates remained among the highest in the world. The highest estimated levels were in Armenia, Azerbaijan and Georgia, where surveys indicate that women will have close to three abortions each on average in their lifetimes. The U.S. abortion rate dropped by 8% between 1996 and 2003, but remained higher than rates in many Northern and Western European countries. Rates increased in the Netherlands and New Zealand. The official abortion rate declined by 21% over seven years in China, which accounted for a third of the world's legal abortions in 1996. Trends in the abortion rate differed across age-groups in some countries. CONCLUSIONS: The abortion rate varies widely across the countries in which legal abortion is generally available and has declined in many countries since the mid-1990s.

Reasons why women have induced abortions: a synthesis of findings from 14 countries.

OBJECTIVE: Many reasons inform women's reproductive decision-making. This paper aims to present the reasons women give for obtaining induced abortions in 14 countries. STUDY DESIGN: We examined nationally representative data from 14 countries collected in official statistics, population-based surveys, and facility-based surveys of abortion patients. In each country, we calculated the percentage distribution of women who have abortions by main reason given for the abortion. We examined these reasons across countries and within countries by women's sociodemographic characteristics (age, marital status, educational attainment, and residence). Where data are available, we also studied the multiple reasons women give for having an abortion. RESULTS: In most countries, the most frequently cited reasons for having an abortion were socioeconomic concerns or limiting childbearing. With some exceptions, little variation existed in the reasons given by women's sociodemographic characteristics. Data from three countries where multiple reasons could be reported in the survey showed that women often have more than one reason for having an abortion. CONCLUSION: This study shows that women have abortions for a variety of reasons, and provides a broad picture of the circumstances that inform women's decisions to have abortions. IMPLICATIONS: Future research should examine in greater depth the personal, social, economic, and health factors that inform a woman's decision to have an abortion as these reasons may shed light on the potential consequences that unintended births can have on women's lives.

Correction: Characteristics of women obtaining induced abortions in selected low- and middle-income countries.

[This corrects the article DOI: 10.1371/journal.pone.0172976.].