**2. Unintended pregnancy after the use of contraception**

The term "family planning" has been used synonymously with contraceptive practice. In this review, we focus on interventions for failed contraceptive behavior or methods and address unsafe abortion as a preventable outcome.

#### **2.1. Unintended pregnancy**

Ineffective contraceptive use contributes to unintended pregnancy. In many Eastern European and South Asian countries, two-thirds of abortions are estimated due to contraceptive failure, mostly from traditional method use, and one-third are due to unmet need for contraception [2, 3]. In developed countries, it has been reported that most abortions occur as a result of contraceptive failure, and a small proportion are due to nonuse of contraception [5]. Based on the data of the National Survey of Family Growth in the United States, the overall failure rate for reversible methods declined from 12% in 2002 to 10% in 2006–2010. Long-acting reversible contraceptives (the IUD and the implant) had the lowest failure rates (1%) and oral pills with the modest failure rate (6%), while condoms and withdrawal carried the highest probabilities of failure (13% and 20%, respectively) [6].

Unintended pregnancies unnecessarily expose women to the risks associated with pregnancy, unsafe abortion, and childbirth, thereby contributing to maternal mortality and morbidity. It has been estimated that 250,000 maternal deaths could have been prevented by contraception and an additional 30% of maternal deaths avoided by fulfillment of the unmet need for contraception in 2008 [7]. A reduction in the number of unintended pregnancies is the greatest health benefit of contraception.

#### **2.2. Impact of unsafe abortion**

**Abortion**

**N**

**% (95%** 

**N**

**% (95% UI)**

**N**

**% (95% UI)**

**N**

**% (95% UI)**

**N**

**% (95% UI)**

**N**

**% (95% UI)**

**N**

**% (95% UI)**

170 Family Planning

**UI)**

Worldwide Developed

1100

7.5%

2000

13.8%

2400

16.3%

1900

12.9%

690

4.7%

2900

20.0%

3600

24.7%

(19.5–33.9)

(16.6–27.5)

(2.4–11.1)

(10.0–16.8)

(11.1–24.6)

(10.1–22.0)

(5.7–11.6)

regions

Developing

192,000

7.9%

76,000

3.1%

659,000

27.1%

341,000

14.0%

260,000

10.7%

232,000

9.6%

668

27.5%

(19·7–37.6)

(6.4–14.3)

(5.9–18.7)

 al. [1].

(11.1–17.4)

(19.9–36.4)

1. Data shown are the estimated proportion of cause of death (%) with 95% uncertainty interval (95% UI); 2. Revised from Say et

(1.7–5.4)

(4.7–13.2)

regions

**Table 1.**

Distribution of causes of deaths by millennium development goal regions.

193,000

7.9%

78,000

3.2%

661,000

27.1%

343,000

27.1%

261,000

10.7%

235,000

9.6%

672,000

27.5%

(19.7–37.5)

(6.5–14.3)

(5.9–18.6)

(19.9–36.2)

(19.9–36.2)

(1.8–5.5)

(4.7–13.2)

**Embolism**

**Hemorrhage**

**Hypertension**

**Sepsis**

**Other direct causes**

**Indirect cause**

The World Health Organization defines unsafe abortion as "a procedure for terminating a pregnancy that is performed by an individual lacking the necessary skills, or in an environment that does not conform to minimal medical standards, or both" [4]. Unsafe abortions and abortion complications as well as the demand for postabortion care also vary remarkably by geographic region. In many low- and middle-income countries (LMIC), abortion is illegal or highly restricted, leading some women to seek unsafe abortions. About 7 million women are treated for complications from unsafe abortion procedures annually in LMICs [8]. Two studies indicate that at least 8% of maternal mortality is due to unsafe abortion and the contribution of abortion may be as high as 18% of these deaths [1, 9]. Factors that increase morbidity and mortality of unsafe abortion include lack of provider skill, poor technique, unsanitary conditions for performing the procedure, lack of appropriate equipment, use of toxic substances, poor maternal health, increasing gestational age, and lack of access to postabortion care [10]. Prevention of unsafe abortion is crucial and requires a multipronged approach including improved access to and accessibility to safe abortion procedures and provision of high-quality postabortion medical care [9, 10].

comparison to surgical abortion, first-trimester medical abortion is more painful, less effective, less acceptable, and associated with more negative experiences and complications after the medications [17]. In the second trimester, surgical abortion is as effective as medical

Interventions for Failed Family Planning http://dx.doi.org/10.5772/intechopen.72239 173

A systematic literature review assessed the main reasons for women in early pregnancy to choose medical or surgical abortion [19]. Women opted for medical abortion because they thought the method being "more natural," wished to have abortion in one's home, and fear of complications. Women selecting surgical abortion viewed the process being quicker and safer, lesser pain, and bleeding. Women made decisions based mainly on rational information from professionals, also on emotions, and especially fears. Support techniques for an

Surgical approach is the long-standing standard for safe induced abortion through either dilation and curettage (D&C) or vacuum aspiration (VA) [14]. Various methods of pain control for surgical abortion were used: paracervical block, oral medications (nonsteroidal anti-inflammatory drugs, anxiolytics, opiates) with cervical block, intravenous (IV) mild to moderate sedation, and general anesthesia. The most effective pain control during firsttrimester abortion has not been proposed, but most women reported lesser pain when given

Cervical dilation is generally needed before surgical intervention. Cervical dilation is generally needed before surgical curettage. As a general rule, the cervix is dilated to the width in millimeter equal to the gestational age in weeks. For example, the cervix is dilated to 7 mm for a 7-week gestation. Serial Hegar's dilators were inserted until an appropriately sized curette can be introduced safely without a force to avoid cervix laceration (which would create a false passage into the cervix and risk excessive bleeding and severe uterine perforation). The curette is then used to gently scrape the uterine wall and remove the tissue in the uterus,

If there is difficulty with dilation, try slowly twisting the dilator to find the pathway through the cervix. An OS Finder or uterine sound can also be used for this purpose. The cervical canal and uterus can also be visualized with ultrasound guidance, allowing direct visualization of the dilator in the cervix. Cervical ripening agents, such as osmotic dilators or misoprostol, can help soften the cervix and ease dilation. For early gestations when dilation is difficult, consider delaying the procedure for cervical preparation or offering a medical abortion instead.

Instead of sharp curettage, first-trimester surgical abortion can be performed by using suction to remove retained products of conception through the cervix. Manual vacuum aspiration

abortion [18].

informed consent are especially needed [19].

**3.3. Surgical termination**

IV sedation [20].

*3.3.1. Dilation and curettage (D&C)*

*3.3.2. Vacuum aspiration (VA)*

which is examined to ensure the procedure is complete.
