Induced abortion is an age-old practice that still continues. Estimates of induced abortions in the developing world alone account for 30 million incidences every year. The figure stands at 3.4 million in Africa, 11.9 million in East Asia, anything between 5.2 million and 12.5 million in South and South-East Asia; and between 4.4 million and 6.2 million in Latin America. In other words, of all births averted by either contraception or abortion, up to one-third are done by induced abortions alone in Africa.

In most developing countries, induced abortion is illegal and unsafe. Of the 20 million unsafe abortions that occur each year, as many as 70,000 result in inevitable death. That is a case fatality of 0.4 per 100. The highest case fatality rate is in Africa (0.6). The risk of dying from an unsafe abortion is much higher in developing countries, 1 in 250 procedures, than in the developed world where the figure is 1 in 3,700.

Of the unsafe abortions that are carried out, as much as 90 per cent happen in developing countries. But then, that is only the tip of the proverbial iceberg - death is not the only tragic outcome of such abortions. Many of those who do survive the abortions live to lead a life of unmitigated complications. Problems range from sepsis, haemorrhage, uterine perforations and cervical trauma that often lead to problems of infertility, permanent physical impairment and chronic morbidity.

Even in those countries where abortions are legal, abortions are not always safe. As far as illegal abortions are concerned, 25 per cent are carried out in Latin America, 25 per cent in the erstwhile Soviet Union, 13 per cent in India and 10 per cent in sub-Saharan Africa. This is ironical since abortion-related deaths are supposed to decrease when restrictions are lessened. Death rates dropped by 85 per cent in five years since it was legalised in the United States. In Romania, for instance, abortion-related deaths had risen by a whopping 600 per cent between 1966 and 1984, dropped by 67 per cent after the practice was legalised in 1990.

Despite the hazards posed by illegal and unsafe abortions, only 22 per cent of the 190 countries in the world have abortion laws allowing it on request. Even developed countries like the United Kingdom and Finland only offer abortion when it is justifiable for health as well as economic and social reasons. In more than 80 per cent of developed countries, abortion is permitted not only to save the woman, but also to preserve the physical health of the woman, to preserve her mental health, in case of rape or incest, and when there is foetal impairment.

These reasons are much less accepted in developing countries. Only 26 per cent of these countries allow abortion in case of rape or incest and only 23 per cent allow it in case of foetal impairment. If that is not bad enough, only 6 per cent (including Albania, China, Cuba, the Democratic Republic of Korea, Tunisia, Vietnam and the breakaway countries of the former Soviet Union) allow abortions on demand.

For most women in developing countries where abortion is illegal and/or unsafe, contraception may offer a better fertility regulation option. In Nepal, unplanned pregnancy accounts for 95 per cent of induced abortion. In the Dominican Republic barely 25 per cent of the women who became pregnant unintentionally used contraceptions. In Colombia, the figure was 79 per cent. Yet, it is not that all contraception methods have had desirable results. IUD in situ was the overriding reason for contraceptive failure in China, a country where IUD users constitute 85 per cent of the total users. In Cuba, it was found that three out of every four women who had an abortion over a period were using a modern method of contraception.

It is only in recent times that studies of contraceptive behaviour and needs have started taking into account gender dynamics in sexual relations and reproduction. A primary reason for non-use of contraception in Nepal was the opposition from a woman's husband. Many women were under tremendous pressure from their husbands and in-laws to get pregnant. In Mauritius, a number of women resorted to abortion because of their husband's refusal to use a family planning method. Women in most countries lack decisionmaking power vis-à-vis their fertility regulation behaviour.

Studies conducted in African and Islamic countries have shown that programmes involving husbands contribute to the successful use of modern contraceptives. In a study of first-time use of DMPA (Depotmedroxyprogesterone) among rural women in Bangladesh, those whose husbands approved of family planning had significantly longer use durations than those whose husbands disapproved.

The quality of reproductive health care services is a key factor in an individual's or couple's ability to initiate and sustain the use of fertility regulation methods and the essential elements of high quality care are now widely recognised. The studies mentioned in this book point to the fact that the starting point for quality abortion care is to ensure that all women have access to a safe procedure.

It is essential that abortion care be linked to family planning services in order to reduce the need for abortion, particularly where it is illegal or not easily accessible. In these situations, women are unlikely to get family planning services from clandestine providers and thus remained vulnerable to additional unwanted pregnancies and repeat unsafe abortion.

The Chile study provides an example of what can be accomplished when services are well-integrated. When women determined to be at high risk for abortion had individual discussions in private and in their homes about their contraceptive needs and preferences with a supportive counsellor, their use of contraception increased noticeably and abortions in the community declined. In the control study community where no intervention had taken place, abortion ratios increased by 30 per cent.

The obvious need for safe, accessible and affordable methods of pregnancy termination requires a closer study of the different possible approaches to safe medical abortion by biomedical scientists. In some of these studies, the suggestion for easier access to medical abortions was made by the women themselves. In Mauritius, where abortion is ruled a criminal act, the use of misoprosol (cytotec) to induce abortion was reported by 36 per cent of women, as high as the use of crude methods such as inserting bicycle spokes, jumping from heights, massage and herbs.

The studies present a strong case for letting family planning workers and abortion workers at the primary level play a role in efforts aimed at reducing the practice of unsafe abortion. In the Philippines, traditional practitioners, despite their use of unsafe methods are more popular than medical doctors throughout the country mostly because they are less expensive and women are assured of complete confidentiality.

There are research gaps too. Little attention has been given to what makes women uncomfortable, both physically and psychologically, as they go through the experience of induced abortion. Women's views and provider skills regarding different abortion techniques and types of pain management need to be studies in various settings, particularly the use of menstrual regulation.