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Abortion in humanitarian and conflict settings

  • Page updated onFebruary 26, 2025
Abortion in humanitarian contexts
Photo: Bruno Abarca

Eliminating unsafe abortion is a global priority, both from a public health and global health perspective, and from a human rights and reproductive rights perspective. Achieving this requires removing legal and social barriers to voluntary termination of pregnancy, but also ensuring the availability of accessible reproductive health services that include both contraception and safe abortion care.

Beginning in 1994, the sexual and reproductive health and rights of refugee women were brought to the table of global health and humanitarian action. However, since then and for more than two decades, safe abortion care in humanitarian settings has lagged behind these advances. A number of changes around 2018 could change this scenario.

Abortion is a necessity for millions of women

Abortion is a necessity for millions of women with unwanted pregnancies

There is a close relationship between unwanted pregnancies and voluntary termination of pregnancy. While the percentage of pregnancies that end in induced abortion is 29%, this percentage is much higher (61%) if we consider only unwanted pregnancies. It is thus estimated that, every year, 73 million unwanted pregnancies end in induced abortion.

This close relationship between unwanted pregnancies and induced abortions exists everywhere. The dynamics of this relationship, however, differ according to context. Twenty-five years ago, the abortion rate was higher in rich countries than in poor countries. Families in the former wished to have few children, while in the latter families wished to have many. Today, however, families in rich countries have easy access to contraceptives, which has led to a reduction in the abortion rate. Families in poor countries, however, already desire smaller families, but there are high barriers to access to contraceptives. As a result, today, the percentage of unwanted pregnancies that end in voluntary termination of pregnancy in low-income countries (40%) is very similar to that in high-income countries (43%).

Overall abortion rates
Average induced abortion rates by country between 2015 and 2019. Guttmacher Institute, 2022.

Legal restrictions on abortion do not reduce it: they make it more dangerous

Legal restrictions on abortion do not reduce unwanted pregnancies or the practice of abortion

Abortion is a very safe procedure when performed by qualified personnel following up-to-date medical protocols. It is estimated that less than one maternal death occurs per 100,000 procedures. However, it is legally restricted in many countries. In some of them it is banned altogether, while in others it is allowed only in exceptional cases, such as to save the mother's life. In general, there are greater legal restrictions on abortion in countries with fewer resources.

However, this does not appear to have any deterrent effect on unwanted pregnancies. Moreover, unwanted pregnancies are more frequent in countries that restrict access to abortion, and less frequent where abortion is widely legal. Something similar occurs with abortion: its practice is higher in countries that restrict it legally. Moreover, in countries that seek to restrict abortion, the percentage of unwanted pregnancies that end in abortion has risen from 36% to 50% over the past 30 years. This increase has been greater than the global average.

Barriers to abortion, however, increase danger to lives of poorer women

Restrictions on abortion force them to be performed illegal, clandestine and unsafe. This also occurs in places where, despite abortion being legal in many cases, there are numerous barriers to access to accredited centers. When abortion is performed using outdated and dangerous techniques, or by unskilled personnel, an otherwise safe procedure poses a high risk of complications.

45% of abortions are unsafe. However, while this percentage is only 12.5% in developed countries t and where it is mostly free, it reaches 74.8% in countries where it is severely restricted and exceeds 85% in Central and West African countries. In fact, 97% of unsafe abortions occur in developing countries. Some are very unsafe. In these, not only have they been performed using outdated techniques or without the support or information of trained personnel, but they have also been performed using dangerous methods. These include ingestion of caustic substances, introduction of sharp elements and foreign bodies through the vagina, or the use of traditional remedies. In Africa, two-thirds of unsafe abortions are of this type.

It is estimated that between 8% and 18% of maternal deaths are due to abortion complications, resulting primarily from unsafe abortions. Each year some 68,000 women die due to consequences of unsafe and more unsafe abortions. These consequences include hemorrhage, infections and poisoning from substances ingested in an attempt to cause the abortion. In addition, in many cases they cause sequelae such as chronic infections, infertility or trauma. In humanitarian contexts, this occurs more frequently, while there are also more barriers to accessing health care for complications.
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Abortion care in humanitarian contexts begins to make headway

For years, there has been only limited progress in postabortion care.

In 2004, the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) published a major assessment of reproductive health progress on the humanitarian agenda. This analysis found only limited availability of postabortion care services (care provided after a spontaneous abortion, or complications resulting from an induced, usually unsafe, abortion). Safe abortion care in humanitarian settings was not even assessed. The IAWG revised its 1999 reproductive health field manual, with an update in 2010 that finally included a chapter on comprehensive abortion care. However, this also failed to make any real practical progress.

Ten years after the first evaluation (and twenty years after the Cairo conference), in 2014, a new evaluation showed progress and improvements in postabortion care, but again revealed an almost complete lack of access to safe abortion care. Studies in the same period also showed that postabortion care was an almost ignored topic in humanitarian action projects in health and protection. Of 11,347 projects analyzed, for response to 345 emergencies between 2002 and 2013, 3,912 were related to reproductive health. However, abortion care was mentioned in only 13 of them. In all cases, moreover, references were exclusive to postabortion care. Safe abortion care in humanitarian settings was completely ignored in project proposals, as well as in studies on their financing, implementation and outcome evaluation.

Some reasons to avoid addressing abortion in humanitarian contexts are unjustified

Not all of the reasons given by humanitarian actors to avoid addressing abortion have proven to have a sound basis. 

In many cases, abortion has not been seen as a priority. However, there is strong evidence of the increased risk in humanitarian settings of unwanted pregnancies and unsafe abortions and their threat to the lives of women, their families and communities. The need for safe abortion care in humanitarian settings is usually extreme.

There has also been among many stakeholders fear of undertaking complex medical procedures. However, safe abortion protocols are safe, and applicable by well-trained mid-level personnel. Moreover, it can be performed in the same health care units that provide basic emergency obstetric care.

Legal barriers imposed by donors such as the United States do have a terrible impact.

The other major barrier for many humanitarian actors are the legal restrictions of the countries of intervention and those imposed by donor countries. This is especially significant in the case of the United States. In this country, the Helms Amendment to the 1973 Foreign Assistance Act prohibits U.S. funds from being used to perform or promote abortions by U.S. and foreign humanitarian organizations. In addition, the Mexico City Policy (or Global Gag Rule) of 1984 prevents foreign organizations receiving U.S. funds from providing information, performing or making referrals for safe abortion care, either with funds from other donors or with their own funds. This law traditionally goes into effect under Republican administrations and is repealed under Democratic administrations. Although there are exceptions to these laws, both force many NGOs, in order to protect funding for their humanitarian programs, to avoid any abortion-related activities.

As for national laws in the intervention countries, they rarely prevent the practice of abortion altogether. In fact, most countries allow abortion in cases of sexual assault, rape, incest, or when the pregnancy endangers the mental and physical health of the mother.. This, moreover, is supported by numerous legal instruments, supranational human rights protocols, and the United Nations. In fact, today, the World Health Organization recommends that abortion should be available to any pregnant woman who requests it.. Moreover, he is openly against laws based on "assumptions" or requiring authorization from third parties.

Since 2018, safe abortion care in humanitarian settings begins to advance

The 2018 update of the Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings finally includes explicit references to safe abortion care in MISP, to the fullest extent permitted by law in each country or region. This push aims to advance a sexual and reproductive rights approach from the onset of emergencies, with the support of humanitarian donors.

International organizations such as the International Federation of Gynecology and Obstetrics (FIGO) have not only promoted the changes that have led to the updating of the MISP. They have also taken a strong and repeated stand in favor of safe abortion care in humanitarian settings within the legal margins established by each country. Other global actors, such as the World Health Organization or Ipas, have even developed tools that allow humanitarian actors to analyze and understand abortion-related laws in each territory, assess the risks, and act accordingly. The IAWG has also recently published documents to assist humanitarian organizations in their internal transformation to understand safe abortion in crisis contexts as an essential human right for gender equality and prevention of maternal deaths.

Médecins Sans Frontières (MSF) has been very open about its progress on abortion. This NGO, in 2004, had already adopted a policy to provide safe abortion care where needed, to prevent maternal deaths and injuries as a result of unsafe abortions. For years, they also worked to overcome internal barriers related to the negative perception of abortion, or lack of awareness of the importance of safe abortion in saving lives. As a result, MSF went from providing just 74 safe abortions in five countries in 2015 to nearly 35,000 in 33 countries by 2021.

The next step: medical abortion in the community

Methods such as vacuum aspiration or dilatation and evacuation are safe, but have a risk of complications such as infection, bleeding, tissue retention and pain, in some cases. In addition, they require access to health units for the procedure and post-abortion care. This is a major constraint, because of economic and geographic barriers to access, but also because of social barriers, linked to stigma. This affects the poorest and most vulnerable, particularly in humanitarian contexts.

Today it is considered that induced abortion with medications can help overcome many of these barriers and transform the exercise of reproductive rights for millions of women. It is a method employed for years, which has demonstrated safety and efficacy. The necessary medications are not particularly expensive and are safe to take at home. It requires a dialogue between the person who wants the abortion, and the trained person who informs her, advises her, and delivers the medications, so that she can take them at home. The fact that no clinical analysis, surgical capacity or medical equipment is necessary allows the abortion to be performed in the privacy of the home, with full autonomy of the women.

The health personnel who provide the information and medications do not even have to be in a health center or hospital. It can be a community health worker, well trained and supervised to offer an essential service from confidentiality, respect and trust. Again, an essential key to health access lies in community participation, in the role of community agents and in the principles of primary care, as is the case with health promotion, management of common childhood illnesses and acute malnutrition, or community epidemiological surveillance.

Sexual and reproductive health

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