use is not recommended by physicians. abortion is sometimes attempted by causing trauma to the abdomen. the degree of force, if severe, can cause serious internal injuries without necessarily succeeding in inducing miscarriage. in southeast asia, there is an ancient tradition of attempting abortion through forceful abdominal massage. one of the bas reliefs decorating the temple of angkor wat in cambodia depicts a demon performing such an abortion upon a woman who has been sent to the underworld. reported methods of unsafe, self-induced abortion include misuse of misoprostol and insertion of non-surgical implements such as knitting needles and clothes hangers into the uterus. these and other methods to terminate pregnancy may be called "induced miscarriage". such methods are rarely used in countries where surgical abortion is legal and available. safety a likely illegal abortion flyer in south africa the health risks of abortion depend principally upon whether the procedure is performed safely or unsafely. the world health organization (who) defines unsafe abortions as those performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities. legal abortions performed in the developed world are among the safest procedures in medicine. in the united states as of 2012, abortion was estimated to be about 14 times safer for women than childbirth. cdc estimated in 2019 that us pregnancy-related mortality was 17.2 maternal deaths per 100,000 live births, while the us abortion mortality rate is 0.7 maternal deaths per 100,000 procedures. in the uk, guidelines of the royal college of obstetricians and gynaecologists state that "women should be advised that abortion is generally safer than continuing a pregnancy to term." worldwide, on average, abortion is safer than carrying a pregnancy to term. a 2007 study reported that "26% of all pregnancies worldwide are terminated by induced abortion," whereas "deaths from improperly performed procedures constitute 13% of maternal mortality globally." in indonesia in 2000 it was estimated that 2 million pregnancies ended in abortion, 4.5 million pregnancies were carried to term, and 14-16 percent of maternal deaths resulted from abortion. in the us from 2000 to 2009, abortion had a mortality rate lower than plastic surgery, lower or similar to running a marathon, and about equivalent to traveling 760 miles (1,220 km) in a passenger car. five years after seeking abortion services, women who gave birth after being denied an abortion reported worse health than women who had either first or second trimester abortions. the risk of abortion-related mortality increases with gestational age, but remains lower than that of childbirth. outpatient abortion is as safe from 64 to 70 days' gestation as it before 63 days. there is little difference in terms of safety and efficacy between medical abortion using a combined regimen of mifepristone and misoprostol and surgical abortion (vacuum aspiration) in early first trimester abortions up to 10 weeks gestation. medical abortion using the prostaglandin analog misoprostol alone is less effective and more painful than medical abortion using a combined regimen of mifepristone and misoprostol or surgical abortion. vacuum aspiration in the first trimester is the safest method of surgical abortion, and can be performed in a primary care office, abortion clinic, or hospital. complications, which are rare, can include uterine perforation, pelvic infection, and retained products of conception requiring a second procedure to evacuate. infections account for one-third of abortion-related deaths in the united states. the rate of complications of vacuum aspiration abortion in the first trimester is similar regardless of whether the procedure is performed in a hospital, surgical center, or office. preventive antibiotics (such as doxycycline or metronidazole) are typically given before abortion procedures, as they are believed to substantially reduce the risk of postoperative uterine infection; however, antibiotics are not routinely given with abortion pills. the rate of failed procedures does not appear to vary significantly depending on whether the abortion is performed by a doctor or a mid-level practitioner. complications after second trimester abortion are similar to those after first trimester abortion, and depend somewhat on the method chosen. the risk of death from abortion approaches roughly half the risk of death from childbirth the farther along a woman is in pregnancy; from one in a million before 9 weeks gestation to nearly one in ten thousand at 21 weeks or more (as measured from the last menstrual period). it appears that having had a prior surgical uterine evacuation (whether because of induced abortion or treatment of miscarriage) correlates with a small increase in the risk of preterm birth in future pregnancies. the studies supporting this did not control for factors not related to abortion or miscarriage, and hence the causes of this correlation have not been determined, although multiple possibilities have been suggested. some purported risks of abortion are promoted primarily by anti-abortion groups, but lack scientific support. for example, the question of a link between induced abortion and breast cancer has been investigated extensively. major medical and scientific bodies (including the who, national cancer institute, american cancer society, royal college of obgyn and american congress of obgyn) have concluded that abortion does not cause breast cancer. in the past even illegality has not automatically meant that the abortions were unsafe. referring to the u.s., historian linda gordon states: "in fact, illegal abortions in this country have an impressive safety record.": 25 according to rickie solinger, a related myth, promulgated by a broad spectrum of people concerned about abortion and public policy, is that before legalization abortionists were dirty and dangerous back-alley butchers.... he historical evidence does not support such claims.: 4 authors jerome bates and edward zawadzki describe the case of an illegal abortionist in the eastern u.s. in the early 20th century who was proud of having successfully completed 13,844 abortions without any fatality.: 59 in 1870s new york city the famous abortionist/midwife madame restell (anna trow lohman) appears to have lost very few women among her more than 100,000 patients—a lower mortality rate than the childbirth mortality rate at the time. in 1936, the prominent professor of obstetrics and gynecology frederick j. taussig wrote that a cause of increasing mortality during the years of illegality in the u.s. was that with each decade of the past fifty years the actual and proportionate frequency of this accident has increased, due, first, to the increase in the number of instrumentally induced abortions; second, to the proportionate increase in abortions handled by doctors as against those handled by midwives; and, third, to the prevailing tendency to use instruments instead of the finger in emptying the uterus.: 223 mental health main article: abortion and mental health current evidence finds no relationship between most induced abortions and mental health problems other than those expected for any unwanted pregnancy. a report by the american psychological association concluded that a woman's first abortion is not a threat to mental health when carried out in the first trimester, with such women no more likely to have mental-health problems than those carrying an unwanted pregnancy to term; the mental-health outcome of a woman's second or greater abortion is less certain. some older reviews concluded that abortion was associated with an increased risk of psychological problems; however, they did not use an appropriate control group. although some studies show negative mental-health outcomes in women who choose abortions after the first trimester because of fetal abnormalities, more rigorous research would be needed to show this conclusively. some proposed negative psychological effects of abortion have been referred to by anti-abortion advocates as a separate condition called "post-abortion syndrome", but this is not recognized by medical or psychological professionals in the united states. a 2020 long term-study among us women found that about 99% of women felt that they made the right decision five years after they had an abortion. relief was the primary emotion with few women feeling sadness or guilt. social stigma was a main factor predicting negative emotions and regret years later. unsafe abortion main article: unsafe abortion soviet poster c. 1925, warning against midwives performing abortions. title translation: "miscarriages induced by either grandma or self-taught midwives not only maim the woman, they also often lead to death." women seeking an abortion may use unsafe methods, especially when it is legally restricted. they may attempt self-induced abortion or seek the help of a person without proper medical training or facilities. this can lead to severe complications, such as incomplete abortion, sepsis, hemorrhage, and damage to internal organs. unsafe abortions are a major cause of injury and death among women worldwide. although data are imprecise, it is estimated that approximately 20 million unsafe abortions are performed annually, with 97% taking place in developing countries. unsafe abortions are believed to result in millions of injuries. estimates of deaths vary according to methodology, and have ranged from 37,000 to 70,000 in the past decade; deaths from unsafe abortion account for around 13% of all maternal deaths. the world health organization believes that mortality has fallen since the 1990s. to reduce the number of unsafe abortions, public health organizations have generally advocated emphasizing the legalization of abortion, training of medical personnel, and ensuring access to reproductive-health services. a major factor in whether abortions are performed safely or not is the legal standing of abortion. countries with restrictive abortion laws have higher rates of unsafe abortion and similar overall abortion rates compared to those where abortion is legal and available. for example, the 1996 legalization of abortion in south africa had an immediate positive impact on the frequency of abortion-related complications, with abortion-related deaths dropping by more than 90%. similar reductions in maternal mortality have been observed after other countries have liberalized their abortion laws, such as romania and nepal. a 2011 study concluded that in the united states, some state-level anti-abortion laws are correlated with lower rates of abortion in that state. the analysis, however, did not take into account travel to other states without such laws to obtain an abortion. in addition, a lack of access to effective contraception contributes to unsafe abortion. it has been estimated that the incidence of unsafe abortion could be reduced by up to 75% (from 20 million to 5 million annually) if modern family planning and maternal health services were readily available globally. rates of such abortions may be difficult to measure because they can be reported variously as miscarriage, "induced miscarriage", "menstrual regulation", "mini-abortion", and "regulation of a delayed/suspended menstruation". forty percent of the world's women are able to access therapeutic and elective abortions within gestational limits, while an additional 35 percent have access to legal abortion if they meet certain physical, mental, or socioeconomic criteria. while maternal mortality seldom results from safe abortions, unsafe abortions result in 70,000 deaths and 5 million disabilities per year. complications of unsafe abortion account for approximately an eighth of maternal mortalities worldwide, though this varies by region. secondary infertility caused by an unsafe abortion affects an estimated 24 million women. the rate of unsafe abortions has increased from 44% to 49% between 1995 and 2008. health education, access to family planning, and improvements in health care during and after abortion have been proposed to address consequences of unsafe abortion. incidence there are two commonly used methods of measuring the incidence of abortion: abortion rate – number of abortions annually per 1,000 women between 15 and 44 years of age; some sources use a range of 15–49. abortion percentage – number of abortions out of 100 known pregnancies; pregnancies include live births, abortions, and miscarriages. in many places, where abortion is illegal or carries a heavy social stigma, medical reporting of abortion is not reliable. for this reason, estimates of the incidence of abortion must be made without determining certainty related to standard error. the number of abortions performed worldwide seems to have remained stable in the early 2000s, with 41.6 million having been performed in 2003 and 43.8 million having been performed in 2008. the abortion rate worldwide was 28 per 1000 women per year, though it was 24 per 1000 women per year for developed countries and 29 per 1000 women per year for developing countries. the same 2012 study indicated that in 2008, the estimated abortion percentage of known pregnancies was at 21% worldwide, with 26% in developed countries and 20% in developing countries. on average, the incidence of abortion is similar in countries with restrictive abortion laws