In developing countries complications of unsafe abortion cause between 50,000 and 100,000 women's deaths annually (94, 233, 292). WHO estimates that the proportion of maternal mortality due to abortion complications ranges from 8% in Western Asia to 26% in South America, with a worldwide average of 13% (292). In some settings complications of unsafe abortion cause most maternal deaths, and in a few they may even be the leading cause of death for women of reproductive age (23, 78, 142, 153, 157, 203, 207, 255, 292).

Estimating the worldwide incidence of abortion and abortion-related deaths requires piecing together information from many sources. Where abortion is legal and data collection systems exist, accurate information is available, while in countries where abortion is legally restricted the only available abortion statistics are estimates. The quality of abortion estimates varies greatly among regions and countries. International efforts are underway to improve the quality of data available on both abortion-related deaths and maternal mortality (301).

Latin America. According to estimates from WHO and others, the highest rate of unsafe abortion is in Latin America, where an estimated 4.6 million unsafe abortions take place each year, or 40 per 1,000 women of reproductive age (292). Unsafe abortion is estimated to cause one-quarter of all maternal deaths in Latin America—6,000 deaths each year (13, 292) (see Table 2). Hospital-based studies in some countries have reported higher fractions (240). For example, between 1985 and 1989 unsafe abortion accounted for nearly one-third of maternal mortality at one Colombian hospital (81). At a Brazilian hospital abortion complications accounted for 47% of maternal deaths between 1978 and 1987 (157).

Asia. With the largest population of any region, Asia has the highest absolute number of unsafe abortions—about 9.2 million each year—although the estimated abortion rate is the lowest in the developing world, at 12 per 1,000 women. Nearly half the world's unsafe abortions take place in Asia, almost one-third in South Asia alone. Unsafe abortion accounts for 12% of all maternal deaths in Asia—40,000 deaths each year (292) (see Table 2).

Sub-Saharan Africa. It is African women, however, who are most likely to die when they undergo unsafe abortion; about one of every 150 abortions results in the woman's death (292). An estimated 3.7 million unsafe abortions are performed each year in sub-Saharan Africa, or 26 per 1,000 women, and about 23,000 African women die from complications (292) (see Table 2). Abortion complications account for an estimated 13% of all maternal deaths in Africa (292). In some countries hospital-based studies report much higher percentages. For example, in Ethiopia a hospital-based study estimated that abortion complications accounted for nearly 40% of maternal deaths (297). In Nigeria during the 1980s, at two teaching hospitals abortion complications accounted for 20% (17) and 35% (206) of maternal deaths. At a third hospital 37% of gynecologic deaths were due to abortion complications (8).

Eastern Europe. In Eastern Europe couples have desired small families for decades, yet women have had little access to or confidence in modern contraceptives. By default, abortion has become the primary means of limiting fertility in many Eastern European countries and the Commonwealth of Independent States (CIS) (formerly the Soviet Union) (56, 129, 130). While abortion is legal in these countries, many procedures are performed under unsanitary conditions or by poorly trained providers. Thus complications of unsafe abortion are a major cause of maternal mortality, accounting for 25% to 30% of all maternal deaths in Russia, for example, and an estimated 50% in Albania (56, 136, 213).

Where abortion is legal. In addition to Eastern Europe and the CIS, unsafe abortions also take place in some developing countries where abortion is legal. For example, in India abortion is legal, and yet many women seek abortions outside the formal health system because medical facilities equipped to provide safe abortion are few. Even where services are available in India, problems with confidentiality, quality, and cost deter women from using them. Also, many people are unaware that abortion is legal (47, 94, 123, 212, 280). Of the estimated 5.3 million abortions induced in India in 1989, 4.7 million took place outside approved health care facilities and thus were potentially unsafe (123).

In Turkey, where abortion is legal, it must be performed or supervised by obstetrician-gynecologists, which makes safe abortions inaccessible to most rural women (185). Among Turkish women whose abortions are legal and performed in medical clinics, mortality is 49 deaths per 100,000 procedures, while among women whose abortions take place outside medical clinics, the risk of death is four times as high, at 208 deaths per 100,000 procedures (156).

Also, in Zambia abortion is legal, but many women and service providers are unaware of its legality. Additionally, legal, safe abortion is inaccessible to most women because they must obtain the consent of three physicians (165). Thus, for every woman in Zambia obtaining a legal abortion in 1991, five sought emergency treatment for complications of unsafely induced abortions (41).

Where abortion is restricted. Conversely, even where abortion is restricted by law, safe abortion is usually available to those who can afford it. Throughout Latin America, for example, private clinics offer abortion services; in Brazil some have even advertised in newspapers (94). In Morocco and Iran abortion is generally illegal, but it is reported that women who can pay high fees to medical providers obtain abortions that are safer than those offered by traditional midwives (80, 198). Also, women who can afford to travel go to countries where abortion is legal to obtain safe services.