SummaryBackgroundGlobal 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.MethodsWe 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.FindingsOf the 55· 7 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.InterpretationIncreased 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.FundingUNDP/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.

Summary 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.

Entrenched economic and gender inequities together are driving a globally expanding, increasingly female, human immunodeficiency virus (HIV)/AIDS epidemic. To date, significant population-level declines in HIV transmission have not been observed, at least in part because most approaches to prevention have presumed a degree of individual control in decision making that does not speak to the reality of women's and girls' circumstances in many parts of the world. Such efforts have paid insufficient attention to critical characteristics of the risk environment, most notably poverty and gender power inequities. Even fewer interventions have addressed specific mechanisms through which these inequities engender risky sexual practices that result in women's disproportionately increased vulnerabilities to HIV infection. This article focuses on identifying those mechanisms, or structural pathways, that stem from the interactions between poverty and entrenched gender inequities and recommending strategies to address and potentially modify those pathways. We highlight four such structural pathways to HIV risk, all of which could be transformed: (1) lack of access to critical information and health services for HIV/sexually transmitted infection (STI) prevention, (2) limited access to formal education and skill development, (3) intimate partner violence, and (4) the negative consequences of migration prompted by insufficient economic resources. We argue for interventions that enhance women's access to education, training, employment, and HIV/STI prevention information and tools; minimize migration; and by working with men and communities, at the same time reduce women's poverty and promote gender-equitable norms. In conclusion, we identify challenges in developing and evaluating strategies to address these structural pathways.

Self-managed abortion, when a person performs their own abortion without clinical supervision, is a model of abortion care used across a range of settings. To provide a comprehensive synthesis of the available literature on self-managed abortion, we conducted a systematic search for peer-reviewed research in April 2019 in PubMed, Embase, Web of Science, Popline, PsycINFO, Google Scholar, Scielo, and Redalyc. We included studies that had a research question focused on self-managed abortion; and were published in English or Spanish. The combined search returned 7,167 studies; after screening, 99 studies were included in the analysis. Included studies reported on methods, procurement, characteristics of those who self-managed, effectiveness, safety, reasons for self-managed abortion, and emotional and physical experiences. Numerous abortion methods were reported, most frequently abortion with pills and herbs. Studies reporting on self-managed medication abortion reported high-levels of effectiveness. We identify gaps in the research, and make recommendations to address those gaps.

Women denied an abortion were more likely than were women who received an abortion to experience economic hardship and insecurity lasting years. Laws that restrict access to abortion may result in worsened economic outcomes for women.