• Topic: Advocacy
• Article on Advocacy

KEY POINTS Using contraception saves women's lives by:
1	Avoiding unsafe abortion. Effective contraception prevents unintended pregnancies, which are often ended by unsafe abortions. Unsafe abortions cause nearly 80,000 maternal deaths each year.
2	Limiting exposure to the health risks of pregnancy and childbirth. Unintended pregnancy needlessly exposes women to health risks, especially if good obstetric care is unavailable.
3	Limiting births to the healthiest ages. Childbearing is safer for women between the ages of 20 and 40.
4	Limiting the number of births. Women who give birth four times or more face dramatically higher maternal health risks.

As many as 20 million of the 46 million abortions annually—over 40%—are unsafe (214, 247). They take place outside health care systems, often because abortion is limited by law, and are performed by unskilled providers and under unsanitary conditions (9, 197). Most, but not all, unsafe abortions take place in developing countries where abortion is limited by law (197).

In developing regions deaths related to unsafe abortion are estimated as high as 100–600 deaths per 100,000 abortions (9, 197). In contrast, the mortality rate from complications of legal abortions in 13 countries, most of them developed, for which accurate data are available is 0.6 deaths per 100,000 abortions (93, 197). For survivors of unsafe abortion, postabortion complications can cause disability and infertility (65).

Expanding and improving family planning programs can increase use of effective contraception and thus help to reduce the number of unintended pregnancies and abortions (94). As studies have shown in many countries and at different times, abortion rates have fallen, often substantially, as use of modern contraception has become more widespread (48, 70, 93, 197, 212, 247).

For national health systems, providing family planning widely is a sound investment. Preventing unintended pregnancies saves health care resources that would be required for treating complications of unsafe abortion (197). Such treatment, which often involves hospitalization, blood transfusions, drugs, and other resources, consumes much of hospital budgets (120). Abortion complications often constitute a large percentage of all emergency gynecological hospital admissions (123). In countries where abortion is illegal, as many as two of every three maternity beds are occupied by women hospitalized for treatment of abortion complications, and up to one-half of obstetrics and gynecology budgets are spent treating these complications (9).

For some women, pre-existing medical conditions make pregnancy especially risky. Such conditions include high blood pressure, valvular heart disease, heart disease with blocked arteries, diabetes with vascular disease, a history of or current breast cancer, malaria, sickle cell disease, anemia, tuberculosis, hepatitis, and sexually transmitted infections. Pregnancy may aggravate these conditions, which can prove fatal (90). An estimated 20% of maternal deaths are due to these "indirect" obstetric causes (214).

Among women who do not want to have children, contraception can save lives by avoiding the possible complications of childbirth, which can be especially risky where access to emergency obstetric care is limited. An estimated 67% of maternal deaths are due to complications of childbirth. About 40% of pregnant women have some complication of childbirth (62), many for reasons that are not predictable or preventable (222). About 15% of pregnant women require emergency obstetric care to manage life-threatening complications (62).

Complications of childbirth include hemorrhage (bleeding), sepsis (infection), eclampsia (pregnancy-induced hypertension), and obstructed labor (2, 146, 221, 264). Almost all maternal deaths occur in developing countries, where many women lack access to emergency obstetric care. Until all women have access to adequate obstetric care, family planning remains essential to saving women's lives. Recognizing its importance, countries at the 1994 ICPD agreed that family planning should be a component of maternal health and safe motherhood programs (224).

Estimates of Maternal Mortality, 1990
Region, Country	Maternal Mortality Ratio*	Total Fertility Rate	Lifetime risk of Maternal Death**
World total	430	2.9	1 in 60
More developed regions***	27	1.6	1 in 1,800
Less developed regions	480	3.3	1 in 48
Africa	870	5.6	1 in 16
Eastern Africa	1,060	6.0	1 in 12
Middle Africa	950	6.5	1 in 14
Northern Africa	340	4.0	1 in 55
Southern Africa	260	3.5	1 in 75
Western Africa	1,020	6.4	1 in 12
Asia***	390	2.8	1 in 65
Eastern Asia	95	1.8	1 in 410
South-Central Asia	560	3.6	1 in 35
South-Eastern Asia	440	2.9	1 in 55
Western Asia	320	4.0	1 in 55
Eastern Europe	62	1.3	1 in 730
Latin America &    the Caribbean	190	3.0	1 in 130
Caribbean	400	2.8	1 in 75
Central America	140	3.4	1 in 170
South America	200	2.8	1 in 140
Oceania***	680	2.4	1 in 26
*Maternal deaths per 100,000 live births  **An average woman's lifetime risk of dying from maternal causes. Determined by the risk associated by each pregnancy and the number of times an average woman becomes pregnant during her lifetime. ***Australia, New Zealand, and Japan have been excluded from the regional totals but are included in the total for developed countries. Source: WHO and UNICEF, 1996 (267)
Women in less developed regions face highter risks of dying in pregnancy and childbirth. In regions where obstetric care is scarce and fertility rates are high, the lifetime risk of maternal death is as much as 150 times that of maternal death in more developed regions.

Too young. Each year an estimated 15 million women under age 20 give birth, accounting for more than 1 birth in every 10 worldwide and up to 1 in every 5 in some parts of Africa (182, 214). Women ages 15 to 19 are twice as likely to die from childbearing as women in their 20s (164, 214). Women under age 17 face especially higher risk (68, 154).

Young women who become pregnant are often at risk of obstructed labor if they have not yet grown to their full height or pelvic size (6). Obstructed labor causes death when adequate emergency obstetric care is unavailable (139). Young women are also more likely to suffer from eclampsia, which can be life-threatening to mother and baby (274).

Too old. The health risks of childbearing increase after age 39 (194). Among women ages 40–44, for example, the risk of death is five times higher than among women in their 20s (195). Older women may have accumulated various health problems during their lives, such as hypertension and diabetes, which can cause obstetric complications (139). In addition, older women are more likely to have already had four or more births, which also increases risk.

Fill in national data from Data Table			Programs can reduce the number of maternal deaths from unsafe abortion by ensuring family planning services to prevent unwanted pregnancies. Safe Motherhood Action Agenda (214)
Measuring the Risks of Maternal Death
	Country Data	Developing Country Average
Maternal Mortality Ratio		480
Lifetime Risk of Maternal Death	1 in every ____ women	1 in every 48 women