From a range of studies, WHO estimates that 10% to 50% of women undergoing unsafe abortions in developing countries need subsequent medical care (292). Four factors, along with the overall health of the woman, determine the risk that a woman undergoing an abortion will experience medical complications or die from the procedure—(1) the abortion method used, (2) the provider's skill, (3) the length of gestation, and (4) the accessibility and quality of medical facilities to treat complications if they occur (167, 233).

The most common abortion complications are incomplete abortion, sepsis, hemorrhage, and intra-abdominal injury (9, 150, 154, 155, 292). Except for intra-abdominal injury, all complications can result from either spontaneous abortion (miscarriage) or induced abortion. Left untreated, each can lead to death (133, 150, 154). Also, women surviving immediate abortion complications often suffer life-long disability or face elevated risk of complications in future pregnancies (96, 166, 292) (see side-bar, Maternal Mortality and Morbidity, Preventable Deaths, Avoidable Injuries).

Incomplete abortion. When tissue remains in the uterus after either miscarriage or unsafely induced abortion, the woman suffers "incomplete abortion," the most common abortion complication. Typical symptoms include pelvic pain, cramps or backache, persistent bleeding, and a soft, enlarged uterus (154, 250, 282).

Sepsis. Septic abortion results when the endometrial cavity and its contents become infected (154), usually after contaminated instruments are inserted into the cervix or when tissue remains in the uterus (282). In addition to suffering the general symptoms of incomplete abortion, women with sepsis have fever, chills, and foul-smelling vaginal discharge. Bleeding may be either slight or heavy (154, 250, 282). The first signs of septic abortion usually appear a few days after the miscarriage or unsafe abortion. The infection can quickly spread from the uterus to become generalized abdominal sepsis. High fever, difficulty breathing, and low blood pressure often indicate a more extensive infection (252).

Hemorrhage. Heavy bleeding can occur when incomplete abortion is left untreated. Also, some techniques to induce abortion, such as sharp curettage or inserting sticks or other objects into the cervix can result in intra-abdominal injuries that cause heavy bleeding. Herbs, drugs, or caustic chemicals swallowed or placed into the vagina or cervix can cause toxic reactions and also lead to hemorrhage (154). The risk of postabortion hemorrhage increases with gestational age, as well as with the use of general anesthesia during unsafely induced abortion (48, 285).

Intra-abdominal injury. When instruments are inserted into the cervix to cause abortion, the cervix, the uterus, or other internal organs can be cut or punctured. The most common injury is perforation of the uterine wall. The ovaries, fallopian tubes, bowel, bladder, or rectum also can be damaged (292). Intra-abdominal injury can cause internal hemorrhage with little or no visible vaginal bleeding.

How many women need care? Sepsis and hemorrhage resulting from spontaneous abortion or unsafely induced abortion often are the most common reasons that women in developing countries seek treatment in hospital obstetric and gynecologic wards (155, 231). In Kenya, for example, two hospital-based studies conducted during the 1980s found that women with postabortion complications accounted for 60% of all gynecological admissions (10, 207). In a 7-year study, abortion complications constituted 77% of all emergency gynecological admissions at University College Hospital in Ibadan, Nigeria (150). A recent Egyptian study of 86 public-sector hospitals found that 28,000 women seek postabortion treatment at these facilities each month (62).

Poor women and young women often suffer the most mortality and morbidity from unsafe abortions. Where abortion is restricted, they rarely have access to safe services, and they also are more likely to have unintended pregnancies because they lack access to family planning (60, 94, 210, 211). For example, in Latin America cities, where abortions are increasingly performed by medical providers, poor women are more likely to be hospitalized for abortion complications than wealthy women, who seek safe abortions in private clinics. Poor women are likely to try to induce abortions themselves or go to untrained or poorly skilled providers because they cannot pay doctors' fees (210, 240). In addition to the absence of or distance to medical facilities, cultural factors, such as the inability to travel without a male escort, often limit a woman's access to medical care when complications arise.

Women experiencing spontaneous abortion (miscarriage) need prompt, compassionate medical care. In Egypt, for example, one-third of the women seeking treatment at the 86 public-sector hospitals apparently had experienced miscarriage—they showed no signs of induced abortion and stated that the pregnancy was planned and desired (62). Like women undergoing unsafe abortions, women experiencing miscarriage face unnecessary health risks, permanent disability, or even death where postabortion care is unavailable or ineffective (87, 177, 279).

In addition to causing many deaths and much suffering, abortion complications consume a large portion of health-care budgets and scarce medical resources. In some areas, for example, large amounts of resources such as blood supply are used for treating complications of unsafe abortion (10, 91, 122, 150, 275).