The Democratic Republic of Congo (DRC) is a country located in Central Africa with a population of over 85 million people [5]. The healthcare system in the DRC faces numerous challenges, including a lack of infrastructure, limited access to healthcare facilities, and a shortage of healthcare workers [6]. Although the government has made efforts to improve the healthcare system, progress has been slow due to ongoing political instability and long-lasting conflict in the region [7].

Regarding the legal status of abortion in the DRC, it is permitted only to save the life of the pregnant woman, in accordance with the Maputo Protocol [8]. Abortion is also allowed within the first 90 days of pregnancy in cases of rape or incest. However, access to safe and legal abortion services is limited in the DRC, leading many women to resort to unsafe methods to terminate unwanted pregnancies [9].

The objective of this review is to investigate the economic and social consequences of unsafe abortion on women and families in the Democratic Republic of the Congo (DRC). Unsafe abortion can have serious implications for women's health, well-being, and economic stability, as well as for their families and communities [10].

Due to restrictive abortion laws and limited access to safe services, many women in the DRC resort to unsafe methods, resulting in serious health complications or even death. This places a heavy burden on the healthcare system and leads to economic instability for families who must bear the costs of medical treatment [11].

Furthermore, unsafe abortions have lasting social impacts on women, including stigma, discrimination, and mental health issues. Women who undergo unsafe abortions may face ostracism from their communities, discrimination in education or employment, and psychological trauma [12].

Additionally, understanding the economic and social burdens of unsafe abortion in the DRC is crucial for effective policymaking and healthcare improvements. Policymakers require robust evidence to formulate policies addressing the root causes of unsafe abortions and mitigating their adverse effects on women and families [13].

Ong and colleagues assert that by comprehensively studying these impacts, policymakers can prioritize resource allocation towards improving access to safe abortion services, enhancing healthcare infrastructure, and promoting reproductive health education [14]. The World Health Organization (2023) emphasizes that this understanding empowers policymakers to advocate for legislative reforms that decriminalize and regulate abortion, ensuring women have access to safe and legal procedures that reduce health risks and associated costs [15]. Moreover, recognizing the social burdens helps policymakers design interventions that reduce stigma, support affected women emotionally, and strengthen family and community support systems [16].

Kagaha & Manderson [17] stipulated that healthcare improvements hinge on a deep understanding of the economic and social repercussions of unsafe abortion [17]. Consequently, recognizing the financial strain on healthcare systems caused by treating complications from unsafe abortions, healthcare providers and policymakers can prioritize investments in training healthcare professionals and expanding facilities equipped to handle abortion-related emergencies [18]. Therefore, this understanding facilitates the development of protocols for managing abortion complications effectively, thereby reducing maternal morbidity and mortality [19]. Understanding the psychological and social burdens of unsafe abortion highlights the need for compassionate care and mental health support for affected women [20]. Integrating these insights into healthcare policies can better address the needs of women with unintended pregnancies, thereby improving reproductive health outcomes in the Democratic Republic of the Congo (DRC) [21].

This research assesses the incidence and economic costs of unsafe abortions in the DRC, examining direct medical expenses, productivity loss, and social stigma. It will investigate barriers to safe abortion access, health outcomes, mortality rates, and existing legal frameworks. The study will propose interventions and policy recommendations to reduce unsafe abortions, including a comparative analysis with other sub-Saharan African countries. Engaging stakeholders will ensure comprehensive understanding and support for the solutions.

HEALTH IMPACTS OF UNSAFE ABORTION

Unsafe abortion remains a significant public health concern in sub-Saharan Africa (SSA), as emphasized by the World Health Organization. In 2014, an estimated 8.2 million abortions took place in the region, with approximately 77% classified as unsafe. The abortion incidence rate stands at about 34 per 1,000 women aged 15-44 years [22], significantly contributing to maternal morbidity and mortality and underscoring the urgent need for enhanced reproductive health services [23,24].

In the Democratic Republic of the Congo (DRC), the abortion rate was notably higher at 56 per 1,000 women aged 15-49 in 2016, surpassing the SSA average [25]. Restrictive laws and limited access to family planning services exacerbate these rates, leading to severe health complications. Improving access to contraception and safe abortion services is crucial for enhancing women's health outcomes in the DRC [26].

Unsafe abortion in the Democratic Republic of the Congo poses significant health risks for women, including infection, hemorrhage, uterine perforation, damage to reproductive organs, psychological trauma, pelvic inflammatory disease, sepsis, and infertility [27]. The lack of access to safe abortion services and inadequate post-abortion care exacerbate these risks, highlighting the importance of comprehensive reproductive health services.

High mortality and morbidity rates from unsafe abortions underscore the critical need for accessible and safe abortion care [28]. Unsafe abortions also result in psychological impacts such as guilt and trauma, particularly in environments lacking legal protections and support [29]. Social stigma and discrimination further strain family dynamics and relationships [30].

Comparative studies across sub-Saharan Africa highlight the prevalence and severe consequences of unsafe abortions [31]. Research emphasizes the necessity for effective management strategies to reduce fatalities and emphasizes the impact of unsafe abortions on maternal mortality, advocating for comprehensive reproductive health initiatives [32,33].

In Uganda, unsafe abortions significantly contribute to maternal mortality, despite improvements in maternal health indicators [34]. Studies from Ethiopia and Ghana reveal high prevalence rates among younger, less educated women, urging healthcare systems to prioritize their needs [35,36]. Comparative studies between Nigerian and Central African Republic hospitals highlight varying complication rates, underscoring the need for tailored healthcare responses [37].

Unsafe abortion can have significant long-term health consequences, such as infertility resulting from damage to reproductive organs and chronic pelvic pain caused by infections, incomplete abortion, or uterine trauma [38]. It is crucial to emphasize these risks and encourage individuals to access safe and legal abortion services to safeguard their health and well-being [39].

Furthermore, unsafe abortion significantly contributes to maternal mortality and morbidity in the Democratic Republic of Congo (DRC), where limited access to safe abortion services leads many women to resort to unsafe methods, resulting in high mortality rates due to complications such as hemorrhage, infection, and organ damage [40]. Additionally, unsafe abortion leads to severe morbidity, including infections, sepsis, and other health issues with long-lasting effects on women's well-being [41]. The healthcare system in the DRC faces a burden in managing the consequences of unsafe abortions, highlighting the urgent need for improved access to safe abortion services and comprehensive reproductive healthcare to mitigate the impact on maternal health in the country.

ECONOMIC COSTS

In the Democratic Republic of Congo (DRC), health expenditure and medical bill payments depend heavily on the country's struggling economy. Most healthcare services are paid out-of-pocket by individuals [42]. The low-income levels and high poverty rates make it difficult for many to afford necessary medical treatment. Government funding for public healthcare is limited, leading to inadequate infrastructure and services. Economic challenges like high unemployment rates and low wages further hinder access to essential healthcare [43].

The economic costs of treating complications from unsafe abortions include direct medical expenses such as hospitalization, surgical procedures, medications, follow-up care, and other healthcare services. These costs vary depending on the severity of complications, required medical interventions, hospital stay length, and the healthcare system [44]. Additionally, indirect costs such as lost productivity, income, and long-term health impacts contribute to the economic burden [45].

Factors contributing to unsafe abortions in the DRC include stringent legal restrictions, barriers to healthcare access, economic limitations, societal stigma, low educational attainment, and religious opposition [46]. Women often resort to unsafe methods, resulting in high maternal mortality rates and severe health consequences like infections and organ damage [47]. Vulnerable demographics, such as young, unmarried women and those with low socioeconomic status, are disproportionately affected, especially in rural areas with limited healthcare infrastructure and heightened stigma [48]. Urban areas, though marginally better served, still face significant economic barriers. The economic toll of unsafe abortions includes direct medical expenses such as treatment and hospitalization, necessitating policy reforms for safer, legal abortion options, improved access to contraception, enhanced reproductive health education, and investments in healthcare infrastructure [49].

Efforts to prevent unsafe abortions through access to comprehensive reproductive healthcare services, family planning education, and safe abortion services can reduce economic costs and improve overall health outcomes [50]. Complications from unsafe abortions incur not only direct medical costs but also substantial indirect economic burdens. Indirect costs, such as lost productivity due to hospitalization, recovery periods, and ongoing healthcare needs, can impact the individual's ability to work and generate income [51]. This lost productivity can strain the individual's financial stability and overall economic well-being. Moreover, unsafe abortions may disproportionately affect primary breadwinners, exacerbating financial strain on families and increasing the risk of economic insecurity and poverty [52].

Unsafe abortions in the DRC impose significant direct and indirect costs. Women may experience prolonged recovery periods, impacting productivity at work or in household responsibilities [53]. These complications often require ongoing healthcare, adding strain to already limited resources in urban and rural settings [54]. Addressing these challenges requires comprehensive reforms, including legal adjustments for safer abortion practices, enhanced contraception accessibility, improved reproductive health education, and strengthened healthcare infrastructure for adequate post-abortion care [55].

Long-term health impacts from complications of unsafe abortions perpetuate economic consequences. Individuals may require ongoing healthcare services, incurring additional financial burdens on themselves and their families [56]. These health issues can diminish quality of life and the ability to work and engage in economic activities effectively. Addressing these indirect costs requires a holistic approach that enhances access to safe abortion services, comprehensive reproductive health education, and economic empowerment initiatives. Mitigating indirect economic burdens, efforts can improve economic well-being and health outcomes for individuals and communities [57].

Comparing the economic costs of complications from unsafe abortions with those of safe abortion services and contraception reveals significant long-term cost savings from investing in safe and accessible reproductive healthcare [58]. Unsafe abortions often result in higher direct medical costs due to managing complications, hospitalization, and other necessary healthcare services [59]. In contrast, safe abortion services can prevent these complications and reduce the economic burden on healthcare systems and individuals [60]. Providing contraception services and education generally costs less than managing complications from unsafe abortions therefore, investing in comprehensive family planning programs and ensuring access to contraceptive methods, healthcare systems can reduce economic costs associated with unintended pregnancies and unsafe abortion complications [61]. Prioritizing investments in safe abortion services and contraception can lead to cost savings and better health outcomes for individuals and communities [62].

Beyond economic impacts, unsafe abortions in the DRC have profound social consequences. Women face stigma and discrimination, affecting their mental health and social integration within communities. Families may also experience social ostracization, compounding the emotional distress of abortion [63]. Addressing these social issues is crucial for reducing broader tensions and disparities within communities.

SOCIAL AND PSYCHOLOGICAL IMPACTS

Individual health is a key factor in the accumulation of human capital, influencing the welfare of couples and their socio-economic and psychological development. Psycho-sociological analysis indicates that unintended pregnancy poses a major challenge for public health and safety, imposing significant psychological and social costs on society [64].

According to a report by the World Health Organization (WHO), poverty and health inequalities are critical factors contributing to unintended pregnancies. Numerous epidemiological studies have demonstrated that developing countries experience poorer health outcomes and higher disease burdens compared to more affluent nations [65]. Unintended pregnancies can lead to a decline in the welfare of couples and families, causing psychological distress and social instability, and hindering psycho-social and economic development [66].

Moreover, stigma and discrimination against women who undergo abortions can have profound social and psychological impacts, including emotional distress, social isolation, fears about future reproductive health decisions, professional and educational challenges, compromised physical health, diminished self-esteem, and barriers to accessing needed care [67]. These negative consequences stem from judgment, shame, and marginalization, adversely affecting mental well-being, social connections, and overall quality of life. Therefore, addressing these issues requires promoting empathy, supporting reproductive rights, and fostering a culture of understanding and respect to create a more inclusive and supportive environment for women who have had abortions [68].

Additionally, these consequences can strain family dynamics and relationships, leading to financial burdens, communication breakdowns, and role changes. It is essential for individuals to receive understanding and support from their loved ones to navigate the aftermath of abortions and promote healing and positive family relationships [69]. Studies have shown some psychological consequences for women and their families can include emotional distress, guilt, shame, fear, anxiety, isolation, loneliness, and trauma-related conditions such as PTSD. Women facing domestic violence, discrimination, or trauma may experience anxiety, depression, and PTSD, impacting their well-being and relationships [70].

Furthermore, families may struggle to support and cope with their loved one's emotional struggles, navigating feelings of guilt, fear, and isolation [71]. Hence, seeking support from mental health professionals, counsellors, or support groups is important to address these psycho-sociological consequences and work towards healing and recovery [72]. Fostering open communication, empathy, and understanding within the family unit also plays a crucial role in providing necessary support.

POLICY AND LEGAL FRAMEWORK

In the Democratic Republic of the Congo (DRC), abortion laws are highly restrictive, permitting abortion only when the pregnancy endangers the life of the pregnant woman. The Penal Code criminalizes abortion, severely limiting access to safe and legal abortion services. Consequently, women facing unintended pregnancies often resort to unsafe methods, which pose serious health risks [73]. Efforts to reform abortion laws in the DRC have faced challenges due to cultural, religious, and political factors. However, efforts are underway to align abortion laws with international protocols, such as the Maputo Protocol [74,75].

Nkombondo [76] study highlights disparities in urban slums, emphasizing the importance of accessible abortion care. Kalunga [77] shed light on challenges faced by minors, advocating for intensive management to mitigate maternal-fetal risk.

Conversely, unsafe abortion presents serious human rights implications, including violations of the rights to life, health, non-discrimination, privacy, freedom from torture, information, education, and equality for women and girls [78]. Restrictive laws and social norms impede access to safe abortion services, leading to maternal mortality and morbidity, discrimination, and gender inequality [79]. A human rights-based approach is essential to address these challenges, emphasizing the need for states to respect, protect, and fulfil human rights obligations, including ensuring access to safe and legal abortion services, promoting comprehensive sexuality education, and addressing the root causes of unsafe abortion through gender-responsive policies and programs [80].

Furthermore, advocacy for women's reproductive rights and access to safe abortion services continues in the country [81]. It is recommended to consult official sources or legal experts for the most current information on abortion laws in the DRC due to potential changes in laws and policies. Therefore, addressing these challenges, vigorous efforts are needed to reform policies hindering the reduction of unsafe abortions [82]. However, these include restrictive legal frameworks, abortion stigma, limited healthcare access, the need for healthcare provider training and support, and community engagement [83]. Overcoming these obstacles requires a comprehensive approach involving legal reforms for safe and lawful abortion services, combating stigma through education and awareness campaigns, improving healthcare access, training and supporting healthcare providers, and engaging communities in discussions on abortion and reproductive rights [84]. Therefore, tackling these issues comprehensively, progress can be made in reducing unsafe abortions and ensuring access to safe and legal abortion services for all women.

HEALTHCARE ACCESS AND SERVICES

The Democratic Republic of the Congo faces significant challenges in healthcare infrastructure, including inadequate facilities, personnel shortages, financial barriers, disparities in care quality, and recurrent disease outbreaks [85]. The country is actively enhancing infrastructure, training healthcare professionals, implementing health insurance schemes, and bolstering disease response systems with assistance from international partners [86].

Access to safe abortion services in the country is limited and often restricted due to stringent laws and societal stigma. Although some hospitals offer these services under certain conditions, availability remains insufficient, particularly in rural areas [87]. Efforts are underway to improve accessibility and advocate for legal reforms to ensure women have access to safe and lawful abortion services. Nevertheless, many women encounter obstacles in accessing these services, especially in remote and underserved communities [88].

Research indicates that healthcare providers and facilities in the Democratic Republic of the Congo play a critical role in the prevalence of unsafe abortion practices due to limited access to safe alternatives, leading women to seek unsafe procedures from unqualified providers [89].

According to Mukendi [90], family planning services in health facilities across the DRC are notably lacking, with uneven distribution throughout the country. To enhance access to and utilization of family planning services, efforts should prioritize improving availability and quality at lower levels of the healthcare system and in rural regions, where the majority of the population resides [90].

Consequently, these challenges contribute to medical complications, stigma, and discrimination, endangering women's health. Inadequate post-abortion care exacerbates these risks [91]. Moreover, addressing this issue requires healthcare providers to receive enhanced training and resources to deliver comprehensive reproductive health services, including safe and legal abortion services, contraception, and post-abortion care, safeguarding women's health and well-being and mitigating the impact of unsafe abortions in the DRC [92].

Furthermore, barriers to accessing safe abortion services encompass geographical, financial, legal, social, and informational obstacles [93]. Geographical barriers arise when individuals in remote or rural areas confront limited access to providers and facilities, resulting in extended travel times and increased expenses [94]. Financial barriers can prove prohibitive for individuals lacking insurance coverage or when abortion services are not covered, necessitating substantial out-of-pocket expenses. Although, legal barriers stemming from restrictive laws and regulations may hinder access to safe and legal abortion services [95]. Lastly, social stigma surrounding abortion may dissuade individuals from seeking care due to fear of judgment or discrimination [96]. Addressing these challenges necessitates a comprehensive approach to enhance access, reduce costs, disseminate reliable information, and combat stigma and discrimination.

CASE STUDIES AND INTERVENTIONS

Unsafe abortion is a significant public health issue in the Democratic Republic of Congo (DRC) due to restrictive laws and limited access to safe services. Several effective interventions have been implemented to address this challenge. For instance, post-abortion care services have been successfully introduced. Abeid [97] noted a low uptake of modern contraceptives among women of reproductive age in their study.

Research from Brazzaville highlighted delays in specialist consultations for patients, often attributed to factors such as fear, financial constraints, and socio-cultural practices [98]. Capelli [99] examined community outreach and education, identifying socioeconomic status, education, geography, and marital status as key factors influencing women's access to abortion and its conditions [99].

In Kinshasa, Ntabona [100] demonstrated promising outcomes with an innovative strategy to increase short-term contraception access and build long-term capacity in family planning among healthcare providers, using the ExpandNet framework [100]. Advocacy efforts aimed at reforming restrictive abortion laws in the DRC have also significantly improved access to safe services. Hall [101] highlighted context-specific changes in abortion laws across different settings, emphasizing consistent influencing factors and processes.

Additionally, addressing unsafe abortion in this context requires a multifaceted approach. This includes strengthening reproductive health education, ensuring access to safe abortion services, training healthcare providers, tackling stigma surrounding abortion, implementing supportive policies and laws, providing post-abortion care, engaging communities, and empowering women [102]. Therefore, by taking these steps, it is possible to reduce the incidence of unsafe abortion, prevent complications, and protect women's health and rights in communities.

Public health is not solely a matter of science and medicine; it is deeply rooted in community dynamics [103]. Therefore, in addressing unsafe abortions in the Democratic Republic of the Congo (DRC), advocacy efforts and community initiatives are crucial [104]. This can involve advocacy campaigns to raise awareness and promote progressive reproductive health policies, community education to dispel myths and provide accurate information, training healthcare providers in safe abortion methods, engaging religious and traditional leaders to address stigma, promoting contraceptive access to reduce unintended pregnancies, supporting women's rights organizations, establishing community-based referral systems, and conducting research to inform advocacy efforts [105,106]. Pasquier [107] asserted that, through a multifaceted approach and engagement with various stakeholders, progress can be made in ensuring that women in the DRC have access to safe and legal abortion services.

CONCLUSION

Unsafe abortion imposes significant economic and social burdens on women and families in the Democratic Republic of Congo (DRC). The evidence overwhelmingly demonstrates that the lack of access to safe abortion services leads to increased maternal morbidity and mortality, exacerbating poverty and perpetuating cycles of economic disadvantage. Socially, stigma and legal restrictions further marginalize women seeking reproductive healthcare, hindering their autonomy and well-being. Addressing these challenges requires comprehensive reforms that prioritize women's reproductive rights, expand access to safe abortion services, and foster supportive social environments. By doing so, the DRC can mitigate the economic and social burdens associated with unsafe abortion, promoting healthier outcomes for women, families, and society as a whole.