Women's choice is key to reduce maternal deaths

Abstract

When Savita Halappanavar died in Galway University Hospital, Ireland, last month from sepsis after having been denied a termination of pregnancy during a threatened miscarriage, an outcry went through the developed world. Ireland's restrictive abortion laws have caused public anger before, for example in 1992, when a 14-year-old rape victim was prevented from travelling to England for an abortion but was eventually given the right to abortion on the grounds of suicide risk. Maternal deaths are thankfully now rare in developed countries. But any such death is avoidable and makes it all the more important to critically examine laws and guidelines. The Irish Government should thoroughly review and reassess its ambiguous abortion law. The story is a different one in the developing world. According to global estimates for 2008, of about 350 000 maternal deaths all but about a 1000 happened in developing countries, the majority in Africa. The leading causes are post-partum haemorrhage, hypertensive disorders, sepsis, obstructed labour, and complications from unsafe abortions. Access to safe abortion remains the neglected taboo in discussions about reproductive health and family planning. Every year, of an estimated 43·8 million abortions, 49% are classified as unsafe and nearly all (97%) in Africa are unsafe. The percentage of unsafe abortions has increased from 44% in 1995 according to Gilda Sedgh and colleagues' paper on global abortion rates published at the beginning of this year. And while maternal mortality overall has declined, mortality from unsafe abortions has remained the same at an estimated 47 000 women each year. An additional 5 million women suffer disabilities related to unsafe abortions. Without access to legal and safe abortions, many women will continue to die needlessly. WHO's new guidelines on safe abortions, published in July this year, should form an essential part of each country's plan to reduce maternal deaths. No woman wants to go through an abortion. And while there will always be circumstances when a woman sees abortion as the only solution, the best way to reduce the number of abortions is to give women choice over when and how to plan their families and avoid unwanted pregnancies in the first place. Almost 300 000 maternal deaths were averted in 2008, according to estimates by Saifuddin Ahmed and colleagues, through access to contraceptives. Yet, there are still about 222 million adolescent girls and women worldwide who lack access to family planning. At the London Summit on Family Planning in July, US$2·6 billion in new donor money was pledged to give an additional 120 million adolescent girls and women access to contraceptives by 2020. This is a welcome boost to assert women's rights and choices on how and when to plan a family. However, an extra $4·1 billion would be required to reach everyone who has unmet needs. The new State of World Population 2012 report, entitled By Choice, Not By Chance and published by the United Nations Population Fund on Nov 14, estimates that making voluntary family planning available to everyone in developing countries would reduce costs of health care for women and newborn babies by $11·3 billion annually. So, there would be a substantial net saving regarding costs alone. But immediate health-care cost savings is only one side of the equation. The more pertinent and humane argument is one that links intrinsically with sustainable development. The report makes a strong case that family planning delivers immeasurable rewards to women, families, and communities. Women must be allowed to take part in society beyond reproduction. Adolescent girls' lives should not be restricted by early childbirth, lack of education, and poverty. Deaths and disability from childbirth and unsafe abortions should become a scourge of the past. In 2014, the 20 year anniversary of the milestone Cairo International Conference on Population and Development (ICPD) is the moment in time when we need to take stock. The ICPD Beyond 2014 secretariat was created to deliver a comprehensive review and a special report with recommendations for further action. Together with the 2015 post-Millennium Development Goals discussions, we need to make the strongest effort possible to give every woman in every country the right and choice to decide when and how to plan a family. Not only will there be fewer maternal and child deaths, but also families will lead healthier lives, will be better educated, and will be economically better off. Sustainable development requires the full participation of women in society worldwide.