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.

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According to social exclusion theory, health risks are positively associated with involuntary social, economic, political and cultural exclusion from society. In this paper, a social exclusion framework has been used, and available literature on microcredit in Bangladesh has been reviewed to explore the available evidence on associations among microcredit, exclusion, and health outcomes. The paper addresses the question of whether participation in group-lending reduces health inequities through promoting social inclusion. The group-lending model of microcredit is a development intervention in which small-scale credit for income-generation activities is provided to groups of individuals who do not have material collateral. The paper outlines four pathways through which microcredit can affect health status: financing care in the event of health emergencies; financing health inputs such as improved nutrition; as a platform for health education; and by increasing social capital through group meetings and mutual support. For many participants, the group-lending model of microcredit can mitigate exclusionary processes and lead to improvements in health for some; for others, it can worsen exclusionary processes which contribute to health disadvantage.

Background and methodology Strategies to reduce health systems costs of providing abortion and post-abortion care while simultaneously improving quality of care are well documented but infrequently applied. We created 'Savings', a spreadsheet-based tool that allows policymakers and other stakeholders to estimate and compare the feasibility and sustainability of different strategies of providing abortion and post-abortion care. By applying cost data primarily from Uganda, we showed the per-case costs under four policy and service delivery scenarios. ResultsThe mean per-case cost of abortion care (in US dollars) was $45 within the setting that placed heavy restrictions on elective abortion and used a conventional approach to service delivery; $25 within the restrictive legal setting that used recommended interventions for treating complications; $34 within the legal setting that allowed 250©FFPRHC IntroductionThe United Nations' Millennium Development Goal calling for the reduction of maternal mortality by 75% between 1990 and 2015 1 will not be met without addressing unsafe abortion. Unsafe abortion -defined as "a procedure for terminating unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both" 2 -causes an estimated 13% of maternal mortality globally and is a leading cause of maternal morbidity, such as infection, hemorrhage, cervical laceration, and uterine perforation. 3 The unsafe abortion mortality ratio is highest in Africa at 100 per 100 000 live births. The ratio is 40 per 100 000 live births in Asia and 30 in Latin America and the Caribbean, whereas in developed countries it is only 3. 4 In some developing countries, as much as 50% of obstetricgynaecology budgets may be spent on treating abortion complications. 5 Abortion care has four components: (1) elective induced abortion services; (2) emergency treatment of complications of spontaneous or unsafely performed induced abortion; (3) post-abortion contraceptive counselling and method provision to prevent repeat unwanted pregnancy; and (4) links between elective or treatment services and other reproductive health care. During the last decade, international agreements have affirmed governmental obligations to make abortion services safe and accessible to the extent allowed by law. 4,6 The technical interventions needed to reduce costs to health systems and simultaneously improve the availability and quality of abortion-related care are well understood 3,7 Reducing the costs to health systems of unsafe abortion: a comparison of four strategies hjohnston@icddrb.org elective abortion and relied on a conventional approach to service delivery; and $6 within the liberal legal setting that used recommended interventions.Discussion and conclusions Using recommended technical interventions substantially reduced costs regardless of the legal setting. The greatest reduction in costs (86%) occurred from using recommended interventions within a liberal legal setting rather than usi...

BackgroundHealth systems could obtain substantial cost savings by providing safe abortion care rather than providing expensive treatment for complications of unsafely performed abortions. This study estimates current health system costs of treating unsafe abortion complications and compares these findings with newly-projected costs for providing safe abortion in Malawi.MethodsWe conducted in-depth surveys of medications, supplies, and time spent by clinical personnel dedicated to postabortion care (PAC) for three treatment categories (simple, severe non-surgical, and severe surgical complications) and three uterine evacuation (UE) procedure types (manual vacuum aspiration (MVA), dilation and curettage (D&C) and misoprostol-alone) at 15 purposively-selected public health facilities. Per-case treatment costs were calculated and applied to national, annual PAC caseload data.ResultsThe median cost per D&C case ($63) was 29 % higher than MVA treatment ($49). Costs to treat severe non-surgical complications ($63) were almost five times higher than those of a simple PAC case ($13). Severe surgical complications were especially costly to treat at $128. PAC treatment in public facilities cost an estimated $314,000 annually. Transition to safe, legal abortion would yield an estimated cost reduction of 20 %-30 %.ConclusionsThe method of UE and severity of complications have a large impact on overall costs. With a liberalized abortion law and implementation of induced abortion services with WHO-recommended UE methods, current PAC costs to the health system could markedly decrease.

Abortion-related mortality and morbidity result in significant health system costs. Approximately 42 million induced abortions occur around the world each year, 1 of which an estimated 22 million are conducted under unsafe conditions-that is, by an unqualified provider, in unsanitary conditions or both. 2 At least 65,000 women die annually from complications of unsafe abortion, and close to five million suffer temporary or permanent disability. 3 A recent analysis suggests that in Africa and Latin America, the annual cost of caring for women with complications of unsafe abortion ranges from US$159 million to US$333 million. 4 According to studies from a number of countries where the incidence of unsafe abortion is high, treatment of abortion complications can account for as much as 50% of hospital budgets for obstetrics and gynecology. 5 Abortion-related mortality and morbidity-and their associated health system costs-can largely be avoided through the prevention of unwanted pregnancy and through the provision of safe abortion services and menstrual regulation. 6 The technical and clinical interventions needed to provide safe, accessible and high quality abortion and menstrual regulation services are well known and include using vacuum aspiration or medication abortion instead of dilation and curettage for uterine evacuation; providing services in outpatient facilities, rather than in operating theaters; having midlevel providers instead of specialists provide care; and providing contraceptive counseling and services. 7-21 Each of these interventions has been shown to reduce the cost of care at the individual, facility or health system levels. 9,12,15,[17][18][19][20][21] Despite the advantages of these interventions in terms of safety and cost, they are often not implemented or are used inconsistently, preventing measurement of costs of services at facility or health system levels.Savings-an abortion-oriented costing spreadsheet-was developed by Ipas to generate estimates of the costs of different strategies of providing abortion care. The initial application of the Savings model used published data primarily from Uganda; 22 however, because the abortion law in Uganda is restrictive, some data from other African countries were used to project costs of providing safe and legal abortion-related care. Results suggest that use of recommended technical interventions would substantially reduce costs of providing abortion care.In Bangladesh, the abortion law is also restrictive; however, menstrual regulation-defined as the evacuation of the uterus of a woman at risk of being pregnant to ensure a state of nonpregnancy-is provided by the government as a backup to contraception for women up to 10 weeks from the beginning of their last menstrual period. The procedure is sanctioned by the government and available at all levels of the public health care system. The Bangladesh menstrual regulation program has had many of the recommended best practices for abortion- Health System Costs of Menstrual Regulation and Care For Ab...

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