determinant. In many countries where abortions are legal, large numbers of women have little access to safe services. In some countries where abortions are meant to be legal under specified criteria, there are in fact few provisions for referring women who meet those criteria to abortion providers, and abortions are treated by the health services as though they were illegal under most circumstances. Conversely, there are countries where most abortions are illegal, but where women can find clinics that provide services with relative impunity, as in Colombia.

The problems of access, interpersonal relations, and technical quality of care may well be linked for abortion and emergency treatment of the sequelae of abortion. Even legal and mandated services can be abusive and accusatory (McLaurin, Hord, and Wolf, 1990). Studies in Brazil show poor technical quality of care—the wrong intravenous fluids used and wrong decisions about procedures (Costa and Vessey, 1993). In many countries, including India, induced abortion is legal under various circumstances, but many hospitals have no provisions for referrals or for performing the procedure: For many women in many countries, the right to a safe abortion exists only de jure, not de facto.

In many developing countries, the most common technique used for abortions in hospitals is still uterine evacuation through dilatation and curettage, although the World Health Organization recommends vacuum aspiration in most cases (World Health Organization, 1986). Dilatation and curettage needlessly exposes women to risks of uterine perforation and the risks associated with general anesthesia. Manual vacuum aspiration can be safely delivered in nonhospital settings (McLaurin, Hord, and Wolf, 1990).

Abortions will likely become more common in developing countries in the next few decades. There is very little information about how the necessary medical or paramedical supervision for medical abortions can be assured in practice, and how these services would best be linked with family planning. When providers are properly trained, manual vacuum aspiration should make early abortion safer and less expensive than the dilation and curettage procedure. For both provision of abortions where legal and treatment of incomplete abortions, the equipment and training for manual vacuum aspiration should be made widely available.

Sex-Selective Abortions

Prenatal diagnostic techniques, even those using sophisticated equipment, have spread to some developing countries, so that deformed or unhealthy—or female—fetuses can be identified. There has been a good deal of speculation about the use of such techniques to identify and abort female fetuses. There are three ways of determining the sex of a fetus:



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