Report: Abortion Incidence and Severity of Complications in Liberia

The evolution of safe and effective medical procedures to perform safe abortion, along with providing universal access to such services, has the potential to eliminate unsafe abortion and related deaths entirely (1). However, unsafe abortion contributes about 13% of maternal death (2), with 25 million unsafe abortion occurring annually worldwide (3), majority of which are recorded in low and middle-income countries. Irrespective of the nature of abortion (spontaneous and or induced), and regardless of a country’s abortion legal framework, post-abortion care (PAC) is endorsed globally as an essential emergency obstetric intervention to address complications associated with abortion (4,5).

Liberia, for a long time has had the highest maternal mortality ratios globally at 1,072 deaths per 100,000 live births in 2013 (6), and 742 deaths per 100,000 live births in the latest demographic and health survey (7). Most of these deaths are attributed to preventable and treatable complications, including hemorrhage (25%), hypertension (16%), unsafe abortion (10%), and sepsis (10%) (8). Deaths associated with unsafe abortion are often grossly underestimated, partly because of the social stigma that surrounds abortion and the fact that some deaths are not necessarily reported as linked to abortion (9). Under the Liberian penal code, abortion is only allowed under a limited set of conditions, including to save the life of the pregnant woman and to preserve her physical or mental health, when the pregnancy results from rape or incest or other felonious intercourse, and when the pregnancy has fetal impairment. However, two doctors must certify that a woman/girl meets these conditions before a pregnancy can be terminated, and only a doctor can perform the procedure.

Even with these restrictions, abortion, especially unsafe abortion remain common in Liberia, and previous abortion incidence estimates have ranged from 6% (Demographic and Health Survey) in 2007 (10) to 32% (population-based study) in 2015 (11). In Liberia, adolescent pregnancy rates remain high (30% adolescent pregnancy rate) (7), and is a contributor to unsafe abortion rates in the country, as unintended pregnancy is a precursor to induced abortion (12), and adolescents are particularly vulnerable to lack of safe abortion access (13).

There have been high-level commitments by the Government of Liberia and stakeholders to address the high rates of maternal deaths in the country. Part of these commitments are reflected in the inclusion of unsafe abortion-related maternal morbidity and mortality as a priority investment area under the Liberia Reproductive Maternal Newborn Child and Adolescent Health (RMNCAH) Investment Case of 2016-2020 (8). In December 2019, the Liberia MOH, with support from the CHAI, World Bank/GFF, and UNFPA, developed the first-ever National Comprehensive Abortion Care Guidelines that specify programmatic and clinical interventions for safe and legal abortion and PAC (14). Nevertheless, there still exist several gaps and weaknesses in addressing sexual and reproductive health (SRH) issues that contribute to abortion, such as limited access to modern and effective contraception and absence of comprehensive sexuality education. In 2019, stakeholders in Liberia (including lawmakers) began revisions to the country’s Public Health Law (Title 33), that includes provisions on expanding access to safe abortion. As of July 2022, the revised Public Health Law had passed the Lower House of Parliament. If passed by the Upper House and assented into law, the Public Health Law will effectively repeal the 1976 Liberia Penal Code, thereby expanding access to safe abortion.

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