1.0 Introduction An abortion is the termination of a pregnancy by loss or destruction of a fetus before birth.

It may be either spontaneous when it is also known as miscarriage, or induced, when it is a deliberate termination of pregnancy. Women and their partners who are faced with an unwanted pregnancy often consider abortion. Abortions are categorized as safe or unsafe using World Health Organization (WHO) definitions. The organization defines unsafe abortion as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both (World Health Organization [WHO], 1992). When abortion is performed within a legal frameworkin properly equipped and regulated health facilities, by qualified health professionals with specific training in abortion the procedure is extremely safe (Singh et al., 2009). Improving maternal health was one of the eight Millennium Development Goals set by the United Nations in 2000; key targets are to achieve universal access to reproductive health care and reduce maternal mortality by 75% (from its 1990 levels) by 2015. The Millennium Development Goals emphasize that reductions in maternal mortality cannot be achieved without successfully addressing the issue of unsafe abortion. WHO estimates that about 25% of all pregnancies worldwide end in an induced abortion, approximately 50 million each year. Of these abortion, about 20 million, or nearly half are being performed under dangerous conditions, either by untrained providers or using unsafe procedures, or both (Berer, 2000). Ninety-five percent of these occur in developing countries. Globally, there is a ratio of one unsafe abortion for every seven live births. Abortion mortality accounts for at least 13% of all maternal mortality (WHO, 2007). The WHO estimates that seven women die every hour somewhere in a developing country because of complications arising from unsafe abortions. In Malaysia, no official data are collected on abortions (Asia Safe Abortion Partnership [ASAP], 2008). Unsafe abortion accounts annually for one to five deaths in the last 10 years according to the Confidential Enquiry into Maternal Deaths by the Ministry of Health (Hematram, 2006). A report issued prior to the 1989 amendment of section 312 of the Penal Code estimated an abortion ratio of one in three live births. In addition, induced abortion ratios per 100 pregnancies have reportedly more than doubled, with ratios in urban areas three times as high as in rural areas. It is important to understand that providing access to safe abortion services is a critical intervention to reduce maternal deaths in these contexts (Population Policy Data Bank, 2010).
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Abortions are legally permissible in Malaysia in specific circumstances. However, term abortion is not used and the term termination of pregnancy is used instead. Termination of pregnancy is dealt with unfortunately under criminal law. Section 312 of the Penal Code allows medical practitioners registered under the 1971 Medical Act (meaning all medical doctors practicing legally in this country) to terminate the pregnancy, if he/she is of opinion, formed in good faith, that continuation of the pregnancy would involve risk to the life, or mental or physical health of the pregnant woman than if the pregnancy were terminated. Permissible conditions for abortion in Malaysia include risk to the life of the pregnant women, injurious to the physical health of the pregnant women and injurious to the mental health of the pregnant woman. Any one of these conditions is sufficient. However, this Penal Code does not take into consideration for conditions such as rape or incest, fetal impairment, economic or social reasons and available on request (ASAP, 2008). The interpretation of the existence of the permissible condition is entirely left to a doctor. It is up to the doctor to form an opinion and decide, in good faith, if the pregnancy is injurious to the womans life and physical and mental health. Besides, the Penal Code does not define the meaning of injurious to physical and mental health (Radhakrishnan, 2007). 2.0 Methods of safe abortion The risks associated with induced abortion, though small when abortion is properly performed, increase with the duration of pregnancy. Thus, determining the length of pregnancy is a critical factor in selecting the most appropriate abortion method. Basically there are 2 types of abortion method which are surgical method and medical method. Surgical methods of abortion are the use of transcervical procedures for terminating pregnancy, including vacuum aspiration, dilatation & curettage (D&C), dilatation and evacuation (D&E) and hysterotomy. On the other hand, medical methods of abortion are the use of pharmacological drugs to terminate pregnancy (WHO, 2003). 2.1 Surgical Method 2.1.1 Vacuum aspiration Vacuum aspiration is used for up to 12 completed weeks of pregnancy. This technology relies on the use of a simple hand- held, plastic 60ml aspirator (also called a syringe) with a plunger to generate negative pressure for uterine evacuation. Available aspirators accommodate different sizes of plastic cannulae, ranging from 4 to at least 12mm in diameter. Electric vacuum aspiration
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(EVA) employs an electric vacuum pump. In vacuum aspiration, the cervix must be stretched open to allow the surgeon to insert a plastic tube into the womb. Sharp-edged openings near the tip of the tube help to dismember the baby so the parts are small enough to be sucked out. The surgeon then uses the suction tube to evacuate the placenta from the womb. The remains of the baby are deposited in a jar for disposal (Society for the Protection of Unborn Children, 2010). Manual vacuum aspiration also has the advantage that the syringe can be re-usable after being cleaned and high-level disinfected or sterilized (David et al., 2006). Depending on the duration of pregnancy, abortion with vacuum aspiration takes from 3 to 10 minutes to complete and can be performed on an outpatient basis, using analgesics and/or local anaesthesia.

2.1.2 Dilatation and curettage Dilatation and curettage (D&C) is used during the first 10 weeks of pregnancy. It also known as sharp curettage, involves dilating the cervix with mechanical dilators or pharmacological agents and using sharp metal curettes to scrape the walls of the uterus. This can cause damage leading to the death or premature delivery of a baby in a subsequent pregnancy. Dilatation and curettage is less safe than vacuum aspiration and considerably more painful for women. The rates of major complications of D&C are two to three times higher than those of vacuum aspiration. (WHO, 2003).

2.1.3 Dilatation and evacuation Dilatation and evacuation (D&E) is used from about 12 completed weeks of pregnancy. It is the safest and most effective surgical technique for later abortion where skilled, experienced providers are available (Royal College of Obstetricians and Gynaecologists [RCOG], 2000). D&E requires preparing the cervix with mifepristone, a prostaglandin such as misoprostol, or laminaria or similar hydrophilic dilator; dilating the cervix; and evacuating the uterus using electric vacuum aspiration with 14-16mm diameter cannulae and ovum forceps. A variety of large ovum forceps is used: Sopher, Hern, Bierer, and Kelly placenta forceps. Forceps is needed because the baby's bones are calcified, as is the skull. There is no anesthetic for the baby. The abortionist inserts the instrument into the uterus, seizes a leg or other part of the body and, with a twisting motion, and tears it from the baby's body. This is repeated again and again. The spine

must be snapped, and the skull crushed to remove them (Life Site News, 2010). Depending on the duration of pregnancy, adequate dilatation can require anything from two hours to a full day.

2.1.4 Hysterotomy Hysterotomy is usually used late in pregnancy and is essentially a cesarean delivery. There is little indication for this procedure as the primary method for abortion, because the risk of major complications and death is greater with hysterotomy than for any other technique (Stubblefield et al, 2004). In hysterotomy, the mother's abdomen and uterus are surgically opened and the baby is lifted out. Unfortunately, many of these babies are very much alive when removed. To kill the babies, some abortionists have been known to plunge them into buckets of water or smother them with the placentas. Still others cut the umbilical cord while the baby is still inside the uterus depriving the baby of oxygen (Life Site News, 2010).

2.2 Medical Methods of Abortion Medical methods of abortion have been proved to be safe and effective. The effects of medical methods of abortion are similar to those associated with spontaneous abortion and include cramping and prolonged menstrual-like bleeding. 2.2.1 Mifepristone and prostaglandin Mifepristone with misoprostol or gemeprost has been proved to be highly effective, safe and acceptable for early first trimester abortions (RCOG, 2000). Mifepristone, which binds to progesterone receptors, inhibiting the action of progesterone and hence interfering with the continuation of pregnancy. Treatment regimens entail an initial dose of mifepristone followed by administration of misoprostol, a synthetic prostaglandin analogue, which enhances uterine contractions and helps expel the products of conception. Efficacy rates up to 98% are reported. An oral dose of 200mg mifepristone followed by 800 g misoprostol administered vaginally is an effective regimen (RCOG, 2000). Vaginal misoprostol has been shown to be more effective and better tolerated than misoprostol given orally. An oral dose of 400 g of misoprostol is effective up to 7 completed weeks of pregnancy (WHO, 2003).

2.2.2 Misoprostol or gemeprost alone Misoprostol is a type of prostaglandin. Prostaglandin causes powerful contractions of the womb expelling the fetus, and usually killing him or her in the process. Vaginal administration of gemeprost alone is registered for termination of second-trimester pregnancy in several countries. The recommended dose is 1mg which is given every 3 hours up to 5 times during the first day and repeated the next day if necessary. With this treatment, 80% and 95% of women will abort within 24 and 48 hours, respectively (WHO, 2003). 2.2.3 Other Medical Abortion Agents Methotrexate, which is a cytotoxic drug used to treat cancer, rheumatoid arthritis, psoriasis and some other conditions, has been used in combination with misoprostol as a medical method for early abortion (up to 7 completed weeks since LMP) in some countries where mifepristone has not been available. A recent randomized controlled trial reported an overall 92% success rate with 50mg of methotrexate followed by 800g intravaginally administered misoprostol 6 or 7 days later. Success rate at day 15 was 83% (Creinin, 2000). However, a WHO Toxicology Panel recommended against the use of methotrexate for inducing abortion, based on concerns about teratogenicity. Other agents are used to stimulate uterine contractions and induce abortion from 12 completed weeks since last menstrual period. They include intra-amniotic injection of hypertonic saline or hyperosmolar urea; intra- or extra-amniotic administration of ethacridine; parenteral, intra-amniotic or extra-amniotic administration of prostaglandin analogues; and intravenous or intramuscular administration of oxytocin (WHO, 1997). Most of these methods and routes of administration, however, are invasive and less safe than the newer medical methods. 3.0 Methods of Unsafe Abortion Methods of unsafe abortion include drinking toxic fluids such as turpentine, bleach, or drinkable concoctions mixed with livestock manure. Inflicting direct injury to the vagina or elsewhere include inserting herbal preparations into the vagina or cervix; placing a foreign body such as a twig, coat hanger, or chicken bone into the uterus; or placing inappropriate medication into the vagina or rectum also cause unsafe abortion. External injury also used such as jumping from the top of stairs or a roof, or inflicting blunt trauma to the abdomen. Besides, unskilled providers also improperly perform dilation and curettage in unhygienic settings, causing uterine perforations and infections (WHO, 2007).
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4.0 Reasons of Abortion Abortion is almost always the result of an unintended and unwanted pregnancy. 4.1 Stigma from the society Stigma from society will cause abortion to occur among young, unmarried women and women living with HIV/AIDS who wish to continue with their pregnancies. Most of them face discrimination from multiple sectors in society, including health-care providers who may be judgmental or even refuse to provide prenatal, labor and delivery, or postnatal services. On the other hand, girl who is pregnant is required by her parents or spouse for abortion to solve everyone's problems. Parents often want to get rid of their daughter's pregnancy because they feel embarrassed and shame for everyone to find out. In addition, single woman who had illegally abortion because they do not want to be forced into marriage as in the society getting pregnant before married is considered as bad (Billings et al., 2009)

4.2 Gender differences The gender inequality in our society contributes to the increase of abortion rate. Male dominance in the decision to have sex but lack responsibilities with respect to contraceptive use can cause their partner to pregnant (Christian Voice for Life, 2010). It is especially saddened when some of the irresponsible spouse threatens their partner to break up if not going for abortion. Besides in other country like China, the parents prefer to have son because of the one child policy they had, lead to the abortion after they know the fetus is female. On the other hand, some couples also want at least one son because usually property and rights were still passed down from father to son (Pison, 2004) 4.3 Do not have enough knowledge to avoid pregnancy Women do not have enough knowledge to avoid pregnancy. As a result, contraceptive prevalence is low. Most of women do not use contraceptive because of misconception or misunderstanding information that they obtain from friends and siblings. Information provided by such groups has often been found to be either incomplete or inaccurate. For example, the main reason for not using contraception was fear of side effects of modern contraceptives. There is evidence from qualitative studies that young women believe that modern contraceptives are harmful and can

damage their womb, preventing them from getting pregnant later in life, whereas they did not associate abortion with such a problem (Abiodun & Balogun, 2009). 4.4 Health Concern Most women decide to have abortion due to their health status. Pregnancies at early age can put young women at risk for obstetric fistulae and can be a risk factor for HIV infection (Hindin & Fatusi, 2009). On the other hand, women concern about their personal health included chronic and life-threatening conditions such as depression, advanced maternal age and toxemia make them seek for abortion (Lawrance et al., 2005). Besides, maternal infections, abnormalities of the reproductive organs especially an incompetent cervix (in which the cervix dilates painlessly and bloodlessly in the second trimester), blood group incompatibility and drug ingestion will highly endanger the life of mother. So, abortion can be performed legally when continuation of pregnancy expose greater risk to the life or physical health or mental health of the pregnant women. Furthermore, the birth defects on fetus which can be seen through the ultrasound at the early of pregnancy also can lead to the unsafe abortion (Jacqueline et al., 2006).

4.5 Interfere with the education and work Mostly, the people will go for abortion once having unwanted pregnancy because it will interfere with their education or work (Lawrance et al., 2005). Pregnancy will affect their school performance and makes them to leave school prematurely. This leads them to drop out (Hindin & Fatusi, 2009). Once abort the child, they can live back to their normal life same as usual like other students. Thus, abortion will give a young person the chance to start a new life as she had planned it. Even among older women and women who had children, they use the interference of work will make them go for abortion because they not being able to continue working or to find work while pregnant or caring for a newborn (Lawrance et al., 2005). 4.6 Adolescent girls are often highly vulnerable to sexual coercion and violence. Their changes in appearance during secondary sexual development made them more attractive than before. During this period, they also start to seek for freedom from their parents. When lack of guidance from parents, they are vulnerable to become the victims of rapist. It will become worsen if she becomes pregnant from rape. So, she will seek for abortion to terminate this unwanted pregnancy (Stephens et al., 2009).
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4.7 Economic constraint Women also seek abortion due to the economic constraint. This difficulties such as absence of father, not be able to properly afford care for a child and already had too much children lead to an abortion (Lawrance et al., 2005).

5.0 Consequence of Abortion Legal abortion reduces the risk of unsafe consequences from abortion through preabortion care, safe methods of abortion and follow up cares during recovery period. The

problems occurred when a pregnant mother seeks for clandestine services or self-induced abortion when they are not allowed by law to terminate their pregnancy. Sometimes, the safe services are not available for them even though they are legally entitled to have an abortion. The outcome of complications from unsafe abortion depends on the availability and quality of postabortion care, womens willingness to turn to medical services, and the readiness of medical staffs to deal promptly with the complications. There are several undesirable consequences of unsafe abortion, which include the effects of health and physiological on the woman, and also the economic consequences. Unsafe abortion has an impact on a womans reproductive health and subsequent pregnancies. Early complications of abortion including trauma, hemorrhage and pelvic infection, whereas delayed complications from abortion including chronic pelvic pain, pelvic inflammatory disease, tubal occlusion, and secondary infertility may put the womans health at risk (Mihai, 2006). Besides, some organs such as cervix and uterus may be damaged by the medical instruments during abortion, especially in unsafe abortion which is carried out by an untrained person. The cervical damage during abortion frequently results in a permanent weakening of the cervix. This weakening may result in an "incompetent cervix" which, means they are unable to carry the weight of a later "wanted" pregnancy because cervix opens prematurely, resulting in miscarriage or premature birth. In addition, among women who have undergone abortion in first pregnancy, 66% of them are experiencing miscarriage or premature birth in their subsequent pregnancies. It also increases the risk of ectopic pregnancies and handicapped newborns in the subsequent pregnancy. Ability to carry a success pregnancy is reduced. Infertility is not uncommon among women who have aborted in their previous pregnancy. Also, risk of developing reproductive tract infections is increased especially for those who have gone through
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unsafe abortion. Infection can be induced when a non-sterilized medical instrument is inserted into the uterus or from an incomplete abortion. Endometritis, which is an inflammatory disease caused mainly by bacteria that can lead to infertility is also common in teenagers who have choose for unsafe abortion (WHO, 1998). According to the National Cancer Institute, abortion is one of the risk factors for certain cancers such as breast, cervical, ovarian and liver cancer. Without a supportive environment in which pregnant mothers can express their needs, they are fear and worry. Often, they feel embarrassed for being judged and do not know how to face those entire negative stigma. Many of them experience immediate psychological problems from abortion. They tend to show sense of denial such as feeling relief initially for the abortion but later followed by repressed guilt, sadness, and grieving at the death of the aborted baby. Mostly, they repress feelings of guilt and delaying emotional reactions sometimes for several years with the abortion. They may always live in sad mood and having sudden, uncontrollable crying episodes after abortion. Also, they lost their self-esteem, trust towards men is much destructed. As a result, they become not confident with relationships, and are not ready to commit into a new relationship. They may be feeling depress all time and even intends to commit suicide. There may be some impacts on young girls interpersonal relationships and sexual behavior such as rejection to having sex because of the fear to become pregnant again. Sleeping disturbances due to flashback and nightmares are also major problems of women who have undergone abortion. Furthermore, they might be loss of appetite and do not want to eat. These may slow down the recovery rate of their body. Sometimes, women who have undergone abortion feel discomfort around babies or obsession with babies. They may also showing over protectiveness of child or in contrast they involve in child abuse. Post abortion syndrome (PAS) is a common syndrome among post-abortion women. It is a series of psychological effects experienced by 19% to 60% of women, ranging from mild depression to suicide or attempted suicide. The effects of PAS include drug and alcohol abuse, personal relationship disorders, sexual dysfunction, repeated abortions, communications difficulties, damaged self-esteem and attempt suicide (Mundigo & Indriso, 1999). Besides health impact and psychological impact, financial burden is another outcome of abortion. A long admission to hospital which is associated with high costs may be required as a result of complication from an unsafe abortion, though it is infrequent. The cost of treating septic
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abortion may be three or more times that of a normal delivery (WHO, 1994). One recent study estimated that every year in developing countries, five million women are admitted to hospital as a result of unsafe abortion (Singh, 2006). The treatment of abortion complications in hospital consumes a significant share of resources, including hospital beds, blood supply, medications, anaesthesia and medical specialists. Thus, the consequences of unsafe abortion place great demands on the clinical, material and financial resources of hospitals in many developing countries (Grimes et al., 2006). Major psychological, financial and emotional costs are also incurred by the women who undergo unsafe abortion (Tshibangu, 1984).

6.0 Interventions Certain interventions are needed to reduce induced abortion and unsafe abortion. 6.1 Sex Education Program Worldwide, young people are at risk of unwanted pregnancies and this lead to illegal and unsafe abortion. Thus, sex education is crucial to provide youth with the information and skills needed to make healthy and informed decisions about sex. The sex education program should include information leaflets on sexual health, the development of skills to negotiate sexual encounters, handle condoms, and access services (Henderson et al., 2006). The education can be delivering through role playing so that the youth will understand it clearly. Receiving formal sex education before first sex was associated with abstaining from sexual intercourse, delaying initiation of sexual intercourse, and greater use of contraception at first sex (Mueller, Gavin & Kulkarni, 2008). This in turn will help in reduce incidence of abortion.

6.2 Consider Less Restrictive Law on Abortion To make abortion safe, restrictive laws need to be annulled, amended or replaced. Besides, traditional and, in some cases, religious laws may also require attention when legal change is being contemplated (Berer, 2000). This is because restrictive abortion law may cause inequitable access to abortion services and the resulting threats to womens right to timely health services and their security of person (Crane & Smith, 2006). Furthermore, the earlier in pregnancy that an abortion takes place the safer it is for the womens health and the less complicated for the provider (Berer, 2000). Hence, regulations include putting the abortion decision into the hands of people other than the women herself may not be appropriate and need to be review too. Instead, a
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womans autonomy in deciding whether to continue or terminate a pregnancy should be support (Crane & Smith, 2006). There is data that indicate an association between unsafe abortion and restrictive abortion laws. As evidence, the median rate of unsafe abortions in the 82 countries with the most restrictive abortion laws is up to 23 of 1000 women compared with 2 of 1000 in nations that allow abortion (Haddad & Nour, 2009).

6.3 Improve women access to legal abortion The main barrier restricting access is the misconception by doctors, nurses, women, the media and the public that abortion is not legal (Reproductive Rights Advocacy Alliance Malaysia [RRAAM], 2008). Thus, a series of state-level seminars are needed to educate all private and public sector service providers on abortion law and womans right for abortion services. Besides, there is no official guideline from the Ministry of Health on indications for provision of abortions in a government facility (ASAP, 2008). As a result, the interpretation of the existence of the permissible conditions for abortion service is entirely left to a single medical practitioner. This in turn led to a very restricted accessibility to legal abortion due to different interpretation of the law. Hence, an abortion policy and guidelines from Ministry of Health is needed.

6.4 Counseling before and after abortion Women desiring abortions should be counseled before and immediately after to reduce the risk of injury. At the before-abortion visit, gestational age, condition of the fetus and pathologies may be diagnosed and the risks associated with the use of different abortion methods should be described. While during the after-abortion visit the patient should be check for possible complications and offering contraception ( Briozzo et al., 2006).

6.5 Family planning and contraceptive for young people Unsafe abortion can be due to lack of contraceptives and other reproductive health services for young people. Family planning programs are most often designed for married women, not for young, single women or men. Young people may not know how or where to obtain family planning services while those who do may be discouraged by health workers' judgmental attitudes. Thus, family planning information and services should be made more widely available to adolescents. Moreover, emergency contraception may be offer to adolescents who have
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unprotected sex or who are worried about contraceptive failure (Barnett, 2000). This will help to reduce unwanted pregnancy and thus reduce unsafe abortion as well. 7.0 Conclusion Unplanned and unwanted pregnancies and unsafe abortions are serious public health problems since globally there is a ratio of one unsafe abortion for every seven live births. Furthermore, abortion mortality accounts for at least 13% of all maternal mortality (World Health Organization 1998). In order to achieve improving maternal health which was one of the eight Millennium Development Goals, policymakers, legal experts, religious leaders, health professions and the public play a crucial role in reducing the incidence of abortion. Abortion is almost always the result of an unintended and unwanted pregnancy. A woman who desire abortion may due to stigma from the society, gender differences, not have enough knowledge to avoid pregnancy, health concern, interfere with the education and work and pregnant from rape. In respect of the range of important reasons women decide to terminate pregnancies, womans autonomy in deciding whether to continue or terminate a pregnancy should be support. Instead, the policymakers should consider whether countries even need to have special laws on abortion if restrictive abortion law causing inequitable access to abortion services and resulting in threats to womens health. Moreover, abortion law reform is necessary for making abortion safe since quality of care cannot be assure if safe abortion is not legally sanction. However, there is controversy over right of woman to decide abortion and the fetus right to life. Besides, abortion either safe or unsafe abortion may bring negative impact on the womens health, as well as the economic status. Hence, the most appropriate intervention towards the problem is to prevent the unwanted pregnancy so that no abortion is needed. In order to prevent unwanted pregnancy, sex education and family planning should be providing at all level of the society, especially for adolescent girl since they are often lack of knowledge to avoid pregnancy.

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