Interest in abortion research is reemerging, partly as a result of political changes and partly due to evidence of the contribution of induced abortion to maternal mortality in developing countries. Information is lacking on all aspects of induced abortion, particularly methodological issues. This article reviews the methodological dilemmas encountered in previous studies, which provide useful lessons for future research on induced abortion and its complications, including related deaths. Adverse health outcomes of induced abortion are emphasized, because these are largely avoidable with access to safe abortion services. The main sources of information are examined, and their relevance for assessing rates of induced abortion, complications, and mortality is addressed. Two of the major topics are the problems of identifying cases of induced abortion, abortion complications, and related deaths, and the difficulties of selecting a valid and representative sample of women having the outcome of interest, with an appropriate comparison group. The article concludes with a discussion of approaches for improving the accuracy, completeness, and representativeness of information on induced abortion. Although the prospects for high-quality information seem daunting, it is essential that methodological advances accompany program efforts to alleviate this important public health problem.
PIP: Studies on induced abortion started dwindling after 1984 when the US government stopped financing abortion-related activities. Recently much interest has focused on induced abortion because it is a major cause of maternal mortality in developing countries. A summary of methodological studies is provided. The sources of data for such studies are somewhat deficient official records of legal abortions. In most developing countries abortion is illegal, and scrutiny of hospital records on complication (a 49% rate in a study in Latin America and 46% hospitalization) is a source. Induced abortion surveys of women in reproductive age and retrospective household surveys are other approaches. The World Fertility Survey, a population-based survey, missed 20-50% of spontaneous abortions and even more induced abortions. Expensive prospective studies requiring large samples did not always provide more accurate information either, e.g., in a Sao Paulo, Brazil, study 25% of 1801 women were lost to follow-up. Pregnant women often do not admit their condition. The measurement of complication rates from induced abortions requires examination of the often incomplete and inconsistent records of emergency, surgery, intensive care, pathology, and anesthesia wards and morgue registers. Some women never go to hospitals or are cared for by traditional healers. The measurement of induced abortion mortality could rely on data of vital registration systems (often shoddy), health service records, and community-based surveys. In a 1967 Latin American study, 33% of deaths were misclassified, and 53% were attributed to circulatory causes in an Egypt study. Abortion case identification is confounded by unintentional (16-83% of menstrual regulations are done on nonpregnant women) and intentional reporting errors (50% of those getting an abortion did not report it in Hungary in 1978 according to WHO data).