Essential elements of postabortion care: origins, evolution and future directions.

International Family Planning Perspectives Complications from spontaneous abortions and unsafely induced abortions pose a serious global threat to women’s health and lives. An estimated 46 million induced abortions are performed annually;1 about 20 million are unsafe, and 95% of these take place in the developing world.2 Unsafe abortion accounts for an estimated 13% of pregnancyrelated deaths3—representing approximately 67,000 women4—every year. In many other cases, unsafe abortion causes such long-term consequences as chronic pain, pelvic inflammatory disease, tubal occlusion and secondary infertility.5 Hospital records from developing countries suggest that 38–68% of women treated for complications of abortion are younger than 20;6 while these data suggest that abortion complications take a high toll on adolescents, they represent only young women who make it to a hospital for treatment. The World Health Organization (WHO) estimates that 10–50% of women who have an unsafe abortion need medical care;7 some women who experience spontaneous abortion also need treatment. The tragedy of unsafe abortion—which WHO defines as “any procedure for terminating an unwanted pregnancy [carried out] either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both”—is that it is the most easily prevented cause of maternal death.8 Unmet need for acceptable contraceptive services results in large numbers of unwanted or unintended pregnancies. With one in four women living in countries where abortion is forbidden or allowed only to save a woman’s life,9 safe and legal abortion services are out of reach for many women with an unwanted pregnancy. Some barriers to addressing unsafe abortion and related maternal morbidity have been reduced or eliminated over the last several decades—for example, some laws restricting access to contraception have been lifted or liberalized.10 Other barriers, however, remain; these include limited resources, restrictions on midlevel providers’ performance of uterine evacuation and political sensitivities about abortionrelated issues.11 Although modern contraceptives have become increasingly accessible, use remains low in many countries. An estimated 120–165 million women, including 12–15 million unmarried women, want to prevent or space their pregnancies but are not using a method;12 many resort to unsafe abortion. Even if all contraceptive users were to use methods perfectly all the time, nearly six million unintended pregnancies would occur annually.13 While most health systems provide treatment for abortion complications as part of emergency obstetric care, the infrastructure to make these services widely available usually is lacking in developing countries. Policies that prohibit midlevel providers from offering treatment for abortion complications result in reduced services. Global initiatives with the potential to address unsafe abortion as a preventable cause of maternal mortality—specifically, the Safe Motherhood Initiative, launched in 1987—have been hindered by the perception that unsafe abortion is not a “core” safe motherhood issue (because it is the result of an unwanted pregnancy and is not related to childbirth), and by social and political sensitivities regarding abortion.14 In this comment, we chronicle the development and expansion of a postabortion care model designed to promote interventions that address abortion-related public health concerns even when abortion laws and policies are restrictive. We review years of program experience with the original model, which led to the development of an expanded and updated model, Essential Elements of Postabortion Care (PAC). Implementing the model challenges global public health leaders, donors, technical assistance agencies and ministries of health to work with communities to ensure that all women who want to prevent or space pregnancies can obtain contraceptive services; that all women have access to services to manage complications from abortion, whether induced or spontaneous; and that all women receiving treatment also receive counseling and the reproductive and other health services they need at the treatment visit, as well as follow-up care and contraceptive resupply.