Many women or the friends or family members caring for them delay seeking care after unsafe abortion because they are afraid providers will refuse them care and notify the authorities (219). Some delay seeking care because they are unfamiliar with or afraid of the formal health care system. In some cases, they do not recognize how serious the complications are (219, 253). Still others cannot obtain or pay for transportation to a hospital or pay for medical care or supplies. Young women often delay seeking care even longer than their older counterparts because they fear their parents' reaction or because they do not know how to find health care (see sidebar, Unsafe Abortion Increasing Among Young Women).

Once they reach hospitals or clinics, many women wait for hours, and in some cases, days, before receiving medical attention (2, 46, 128, 134, 177). In Nepal, for example, women admitted to the national maternity hospital with abortion complications once waited one to seven days for treatment (177). Common reasons that care is delayed or unavailable at clinics or hospitals include lack of protocols, misdiagnosis, punitive attitudes among providers, and heavy case loads and hospital overload due to lack of supplies or trained personnel.

Lack of protocols. Women suffering from abortion complications often are not treated immediately because no clear plan exists for postabortion care (14, 135, 138, 154, 219). Without a clear treatment protocol, providers may not know which treatment is the most appropriate for abortion complications or may lack the needed supplies for appropriate treatment. For example, in many countries providers still use general rather than local anesthesia when treating abortion complications, needlessly increasing the preparation time, equipment, and personnel needed for the procedure as well as the woman's health risk and recovery time (95, 186, 238, 277, 282).

Where no clear postabortion care plan has been developed, providers may not understand their responsibility to treat postabortion complications, especially in settings where abortion is prohibited. Treatment may be delayed because providers fear legal action against them. In Bolivia, for example, some staff mistakenly thought that their hospital's policy required them to refuse to treat women suffering complications of incomplete abortion (219). When a plan for postabortion care is developed, all providers must be made aware of the plan and the treatment protocol to avoid delays.

Misdiagnosis. In some cases appropriate treatment is delayed because providers are not immediately aware that a woman's condition is pregnancy-related. Some women may not acknowledge that they have attempted to induce abortion or may not even acknowledge that they are pregnant (218, 282). Also, providers may not recognize the severity of the woman's complication. In Zambia, for example, an 18-year-old suffering from septic abortion was hospitalized for 14 days with a misdiagnosis of malaria before a gynecologist diagnosed her true condition. Despite surgery and appropriate antibiotic therapy, the woman died 8 days later, 22 days after being hospitalized (46).

Punitive attitudes. Deep differences in attitudes toward induced abortion exist among policy-makers and among health professionals around the world. Some health care providers hold judgmental or punitive attitudes toward women who have had abortions, and their attitudes can affect the care that they give postabortion patients (3, 200, 243, 247). Even in countries where abortion is legal, some providers who disapprove of abortion have difficulty separating their personal feelings about abortion from their professional commitment to provide medical care (140, 244).

Some providers feel a need to punish women by delaying treatment, withholding pain medication, or charging higher fees than the actual cost of treatment (3, 172, 243). Some berate women for attempting abortion, for not using family planning, or for having sex in the first place (200, 218). When resources are scarce and personnel are overworked, some providers may resent caring for women who have undergone unsafe abortion, whom they see as a low priority and as bringing the problem on themselves. As one provider in Kenya described it, "The patients are generally handled as criminals or sinners" (242). Because in many cases it is impossible to differentiate between induced and spontaneous abortion, such attitudes affect the care offered to women suffering miscarriage as well as those whose abortion was induced.

Hospital overload. Heavy emergency case loads, lack of supplies and drugs, and shortage of trained personnel also can delay treatment (14, 135, 138, 154). In one Ethiopian hospital, where abortion complications accounted for 41% of maternal deaths, severe shortages of medical equipment, drugs, intravenous fluids, and blood for transfusion compromised the standard of care available for treating all pregnancy-related emergencies, including abortion complications (14). Delays may be even more common at smaller, district hospitals. A study in Bangladesh, for example, found that 15% of district hospitals did not provide blood transfusions and that some smaller facilities did not provide even basic obstetric care, despite having doctors on staff (175). In many countries this lack of care often reflects a larger, systemic problem of inadequate care for all medical emergencies.