The preventable burden of mortality from unsafe abortion among female sex workers: a Community Knowledge Approach survey among peer networks in eight countries

Figures & data

Table 1. Summary of abortion and maternal health status across the eight study countries

	Unintended pregnancy rate (2015–2019, per 1000 women aged 15–49)^Citation34	Abortion rate (2015–2019, per 1000 women aged 15–49)^Citation34	Maternal mortality rate, per 100,000 live births (2017)^Citation35,Citation36	Annual nos. maternal deaths (2017, IHME)^Citation33	Annual nos. deaths from abortion* (% of all maternal) (2017, IHME) ^Citation33	Legal restrictions around abortion^Citation37	De facto access to abortion
Angola	120	33	241	2126	198 (9.3%)	Highly restricted: legal only to save a woman’s life.	PAC (surgical or medical) only. Limited distribution of misoprostal.^Citation38,Citation39
Brazil	67	32	60	2054	206 (10.0%)	Moderate: In cases of rape, to save a woman’s life, and in the cases of anencephaly.	Abortion is common, but many are obtained unsafely.^Citation17
DRC	117	44	473	10,166	1025 (10.1%)	Moderate: To save a woman’s life and to preserve her health, with explicit mention of mental health	Safe services are largely inaccessible despite new legal framework. Limited social marketing and private sales of MA in urban areas.^Citation40
India	62	48	145	39,427	4478 (11.4%)	Liberal: Permitted under a broad range of socio-economic circumstances (including rape, contraceptive failure, fetal impairment)	Limited number of facilities offering abortion. MA commonly available over the counter, accessed with and without prescription.^Citation41
Indonesia	40	25	177	6627	656 (9.9%)	Highly restricted: in medical emergencies, and in cases of severe fetal anomaly	The vast majority of abortions occur outside these legal parameters and many occur under unsafe conditions.^Citation42
Kenya	113	43	342	3990	418 (10.5%)	Moderate: To save a woman’s life and to preserve her health (but with no explicit mention of mental health)	Safe services remain restricted to a small number of hospitals and private clinics. Limited social marketing and private sales of MA.^Citation43
Nigeria	68	33	917	17,982	1062 (5.9%)	Highly restricted: To save woman’s life.	Women mostly self-manage abortion with non-recommended methods outside the formal healthcare system.^Citation44
South Africa	81	30	119	1191	88 (7.4%)	Liberal: No restrictions up to 12 weeks. In second trimester, allowed under certain circumstances (health risk, rape/incest, socio-economic impact).	Freely available in the public sector, but geography and provider attitudes restrict access; high proportion sought in the informal sector.^Citation10

Note: MA = medical abortion.

*Includes spontaneous & induced abortion and deaths from ectopic pregnancy.

Table 2. Mortality among FSW, by country

	No. of group participants	Total no. FSW deaths reported	Mean no. deaths reported per FSW participant	No. (%) deaths due to maternal causes (n = 2112)	No. (%) maternal deaths due to unsafe abortion (n = 1320)	Annual unsafe abortion death count (2018/2019)
Angola	71	52	0.73	6 (11.5)	4 (66.7)	3
Brazil	80	39	0.49	1 (2.6)	1 (100.0)	1
DRC	270	606	2.24	537 (88.6)	304 (56.6)	177
India	152	132	0.87	43 (32.6)	19 (44.2)	4
Indonesia	76	58	0.76	12 (20.7)	4 (33.3)	2
Kenya	175	529	3.02	312 (59.0)	188 (60.3)	116
Nigeria	312	527	1.69	386 (73.2)	216 (60.0)	130
South Africa	144	169	1.17	23 (13.6)	14 (60.9)	4
Total	1280	2112	1.65	1320 (62.5)	750 (56.8)	437

Table 3. Deaths from unsafe abortion, by country

Country (no. of abortion deaths)	Mean age at time of death from abortion	Gestational age (months) at time of death (mean (SD) (N))*	% of abortion deaths outside hospital (home or other) (N)*	% abortion deaths resulting in motherless children	No. motherless children following abortion deaths
Angola (n = 4)	33.5	Unknown	0 (1)	100	12
Brazil (n = 1)	Unknown	Unknown	0 (0)	0	0
DRC (n = 304)	23.0	4.6 (1.9) (286)	66 (301)	75.0	524
India (n = 19)	27.4	3.8 (1.2) (6)	100 (3)	58.0	17
Indonesia (n = 4)	26.8	Unknown	0 (0)	25.0	2
Kenya (n = 188)	25.6	4.8 (1.7) (116)	70 (151)	74.5	263
Nigeria (n = 216)	25.5	4.6 (1.7) (206)	91 (201)	74.5	376
South Africa (n = 14)	24.6	7.0 (–) (1)	0 (0)	64.3	13
Total (n = 750)	24.6	4.6 (1.8) (615)	75 (658)	73.9	1207

*Excludes missing data, denominator N with data shown in brackets.

Table 4. Methods of unsafe abortion resulting in death*

Country (n)	Traditional medicines (herbs, local medicine) (n (%))	Detergent, bleach (ingested or inserted vaginally) (n (%))	Probes, needles or other invasive procedure (n (%))	Unknown medication (pills, injection) (n (%))	Salt and coke/water (n (%))	Surgical procedure (n (%))	Unknown method or other (n (%))	Total (n (%))
Angola (n = 4)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	4 (100%)	4 (100%)
Brazil (n = 1)	0 (0%)	0 (0%)	0 (0%)	1 (100%)	0 (0%)	0 (0%)	0(0%)	1 (100%)
DRC (n = 304)	114 (37.5%)	3 (1.%)	0 (0%)	117 (38.5%)	20 (6.6%)	17 (5.6%)	33 (10.9%)	304 (100%)
India (n = 19)	0 (0%)	0 (0%)	0 (0%)	9 (47.4%)	0(0%)	8 (42.1%)	2 (10.5%)	19 (100%)
Indonesia (n = 4)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	4 (100%)	4 (100%)
Kenya (n = 188)	57 (30.3%)	6 (3.2%)	8 (4.3%)	48 (25.5%)	0 (0%)	22 (11.7%)	47 (25%)	188 (100%)
Nigeria (n = 216)	113 (52.3%)	0(0%)	0 (0%)	48 (22.2%)	0 (0%)	47 (21.8%)	8 (3.7%)	216 (100%)
South Africa (n = 14)	0 (0%)	0 (0%)	0 (0%)	1 (7.1%)	0 (0%)	1 (7.1%)	12 (85.7%)	14 (100%)
Total (n = 750)	284 (37.9%)	9 (1.2%)	8 (1.1%)	224 (29.9%)	20 (2.7%)	95 (12.7%)	110 (14.7%)	750 (100%)

*Some women discussed use of multiple methods and abortion attempts. The final method resulting in death is recorded here.

Table 5. Comparison of study estimates to nationally representative data

	No. participants	Annualised abortion death total*	IHME 2017 abortion deaths†	Study FSW % of national abortion deaths
Angola	71	3	198.0	1.5
Brazil	80	1	205.6	0.5
DRC	270	177	1024.8	17.3
India	152	4	4477.5	0.1
Indonesia	76	2	656.1	0.4
Kenya	175	116	417.9	27.7
Nigeria	312	130	1062.4	12.3
South Africa	144	4	87.9	4.0

*Annualised from 2018 + 2019 deaths, according to the month of data collection in 2019 (Jan–Sept) as reported previously²²

†IHME estimates for abortion deaths include spontaneous abortion.

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