More providers of safe abortion care can save thousands of women's lives

A change in attitudes, increased knowledge and more non-physician healthcare providers trained to perform safe abortions – this is the recipe for increasing the number of caregivers offering abortion care and fighting global maternal mortality, according to a doctoral thesis from Karolinska Institutet on abortion care in India, Sweden and elsewhere. Unsafe terminations claim tens of thousands of lives, particularly in the poorer parts of the world.

"Abortion care provided by midwives is just as safe as when given by doctors," says Dr Susanne Sjöström, who has recently presented her doctoral thesis at Karolinska Institutet's Department of Women's and Children's Health. "The studies included in my thesis stress the extent to which education and knowledge influence the willingness of potential caregivers to perform safe abortions, which is crucial to reducing maternal mortality. We also show that abortion care given by non-physicians is more cost-effective, which is important since most countries have limited healthcare budgets."

From time immemorial women have had unplanned pregnancies, and when their situation has precluded having the baby, they have used a wide assortment of termination methods, often risking their own lives in the process Despite the wealth of knowledge available today about abortion and contraception, unsafe abortions cause at least 23,000 deaths and 7 millions of women with temporary or permanent morbidity every year around the world, most of them in the poorest regions of sub-Saharan Africa. Unsafe abortion also imposes an enormous economic burden on society.

Unplanned pregnancies are preventable if contraceptive methods are available. Medical abortions and medical treatments of incomplete abortions are inexpensive and safe, and the drug misoprostol is widely available. But there are many barriers limiting women's access to safe abortion, including a lack of caregivers, legal proscriptions, poor infrastructure, costs, stigma and women's lack of knowledge.

The availability of caregivers is determined by their medical knowledge and willingness to provide safe abortion care. Society can also increase the number of abortion providers by allowing other medical professionals than doctors to perform abortions, as recommended by the WHO. Dr Sjöström and her colleagues studied factors that influence the availability of caregivers for safe abortions in different settings.

In one study conducted among medical students in India, where abortion has been legal since 1971 but where abortion-related maternal mortality rates remain high, the researchers found that students commonly misunderstood the laws regulating abortion and were uninformed about available abortion methods. The students were hugely affected by the stigma connected with abortion and even though the majority of medical students recognised that unsafe abortions are a huge problem in India, many claimed to be worried about reprisals and said that they were afraid to perform the procedure in their future practice.

Analyses made at a university hospital in Sweden showed that abortion care given by midwives is not only as safe but also much cheaper than when given by doctors. A systematic overview of randomised studies of abortion care also showed that women find that medical abortions and treatments for incomplete abortions administered by nurses and midwives are just as acceptable as those administered by doctors.

"The fact that medical treatment is acceptable to the patient is highly significant for increasing the availability of healthcare," says Dr Sjöström. "If women find the treatment or the caregiver unacceptable they risk turning to untrained or traditional carers, which can have serious health implications."