Passions undoubtedly run high on whether abortion should be legal. But whether you accept the need for abortion or oppose it outright, the most comprehensive survey of global abortion trends since 1995 seems to confirm what many might have suspected 鈥� that women will continue to seek out abortions regardless of whether they are legal or not. It also showed the fastest way to reduce the number of abortions is to provide access to reliable contraception.
The study, which shows that the total number of abortion 鈥� both legal and illegal 鈥� fell worldwide between 1995 and 2003, was published in The Lancet last week (). It compares abortion data from 2003 and 1995 assembled by the World Health Organization and the New York-based Guttmacher Institute, which studies sexual and reproductive health. 鈥淭he total number of induced abortions declined from 46 to 42 million [per year], and for every 1000 women of childbearing age, 29 had abortions, down from 35 in 1995,鈥� says lead author Iqbal Shah of the WHO.
Tellingly, the number of abortions fell almost exclusively in rich countries where terminating a pregnancy is both legal and safe. In poorer countries, where access to abortion is often restricted or illegal, there has been very little progress in reducing the number of abortions, says Shah.
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In such countries, women are prepared to endanger their lives to terminate a pregnancy (see 鈥淏y any means available鈥�). In Africa, for example, where access to safe, legal abortions is almost non-existent, there were 29 abortions per 1000 women of childbearing age in 2003. In Europe, where abortion is widely available and legal (with the exception of Poland and Ireland), the rate was almost identical, at 28.
There is a crucial difference, notes the report. While 98 per cent of abortions in Africa are unsafe, leading to widespread maternal death and disability, less than 1 per cent of European women suffer complications such as haemorrhaging and post-abortion infection. 鈥淢aking abortion illegal doesn鈥檛 stop it happening, and if it happens in a context that鈥檚 not safe, women will die,鈥� says Ann Starrs of Family Care International, a charity in New York lobbying to improve women鈥檚 global health and status.
The European data is skewed slightly by extremely high rates of abortion in eastern Europe and former members of the Soviet Union, where until recently abortions were the cheapest and most reliable method of contraception. But it is balanced by some of the lowest rates of abortion in the world. In Austria, Switzerland, France, Germany, the Netherlands, Belgium and Luxembourg, there were just 12 abortions per 1000 women in 2003. These countries generally have the most abortion clinics and the most liberal abortion laws. 鈥淚t shows that making abortion legal and available doesn鈥檛 increase it,鈥� says Sharon Camp, president of the Guttmacher Institute.
Even in eastern Europe, abortion rates have halved from 90 abortions per 1000 women in 1995, to 44 per 1000 in 2003 鈥� thanks almost entirely to the wider availability of effective contraceptives. 鈥淲e now have a very powerful body of data from multiple countries showing a connection between the rise in contraception availability and a decline in abortions,鈥� says Camp.
Paul Van Look, director of the WHO鈥檚 Department of Reproductive Health and Research, agrees. 鈥淭he eastern European data shows that providing contraceptives works, so countries should now put more effort into prevention instead of prohibition,鈥� he says.
The report itself echoes this: 鈥淎t the root cause of induced abortion is unintended pregnancy.鈥� It also reveals a chronic lack of contraception and family planning advice in countries where it is needed most. The authors estimate that 108 million married women in developing countries want contraception but can鈥檛 get it, resulting in 51 million unintended pregnancies each year. Another 25 million occur because contraceptives are misused or faulty.
Globally, a third of the 205 million pregnancies that occurred in 2003 were accidental. If women鈥檚 access to abortion is severely restricted or outlawed, their only recourse is to have the baby or seek an illegal abortion.
And if they do choose a backstreet abortion, they put themselves at high risk. In a separate study, yet to be published, the WHO estimates that 67,000 women die each year worldwide after unsafe abortions, while 5 million women need hospital treatment for complications, such as blood poisoning or haemorrhaging.
Treating these complications is far more costly than providing safe, early abortions or preventing pregnancies through contraception. 鈥淭he message here is a no-brainer,鈥� says Jill Sheffield, president of Family Care International in New York. 鈥淪upport for family planning reduces unintended pregnancies and that reduces abortions, whether the procedure is legal and safe or illegal and unsafe.鈥�
鈥淔amily planning reduces unintended pregnancy and that reduces abortions, whether legal and safe or illegal and unsafe鈥�
Some countries have relaxed the conditions under which women can access safe abortions. For example, Portugal and Mexico eased restrictions this year, allowing unrestricted access before 10 and 12 weeks of pregnancy respectively. Previously, terminating a pregnancy was only allowed if a woman鈥檚 life or physical and mental health were in danger. As abortion laws are relaxed, governments need to make sure women know their rights, says Van Look. 鈥淚n many places, abortion is so stigmatised that women who are raped or suffer incest, for example, might not realise they鈥檙e eligible for a legal abortion,鈥� he says.
Other countries ban abortion completely. Not only does this drive it underground, it also means women wait until later in their pregnancy to seek an abortion, when the risks are higher, says Beth Jordan, medical director of the US Association of Reproductive Health Professionals in Washington DC.
By any means available
Legal techniques:
- 鈥淢edical鈥� abortion with the pills methotrexate or mifepristone, followed by a prostaglandin. Works up to 8 weeks of pregnancy
- Vacuum aspiration. Uterus contents are sucked out without dilating the cervix during the first 12 weeks
- Dilation and curettage (D&C). Uterus cleared and the lining scraped out. Performed up to 15 weeks
- Dilation and extraction. An injection is used to stop the fetus鈥檚 heart before its bones are crushed. A rare procedure, performed after about 20 weeks. Banned in the US this year by the Supreme Court
Illegal techniques:
Worldwide 48 per cent of all abortions are unsafe and rely on methods such as:
- Drinking turpentine, bleach or tea made with manure
- Inserting herbal preparations into the vagina or cervix
- Poking sticks, coat hangers, chicken bones or feathers into the uterus Jumping from heights
- 鈥淧ummelling鈥�, a massage vigorous enough to shear off the placenta, break the fetus鈥檚 neck, or cause haemorrhage or rupture the uterus
- Hot stones on the abdomen to 鈥渕elt鈥� the fetus
Banned in three countries
Only three countries in the world ban abortions outright: Chile, El Salvador and Nicaragua. But since 1995, there has been a trend for countries to adopt more liberal laws, says the Center for Reproductive Rights (CRR) in New York, which monitors abortion laws.
鈥淐urrently, 70 countries, representing more than 60 per cent of the world鈥檚 population, permit abortion without restriction,鈥� said the centre in July. Since 1995, following a Beijing conference calling on governments to review their abortion laws, 17 of 196 countries the centre monitors have broadened the circumstances in which abortion is legal.
The moves are already paying dividends, according to the WHO. Since South Africa liberalised its abortion laws in 1996, it says, the incidence of post-abortion infection has fallen by 52 per cent.
The reason for the trend is increasing pressure from women鈥檚 groups. 鈥淭here鈥檚 growing acceptance that criminalising abortion violates a woman鈥檚 human rights,鈥� says Luisa Cabal, director of CRR鈥檚 international and legal programme. 鈥淚 believe the trend will continue.鈥�
However, in a minority of countries the tide has turned against abortion. El Salvador introduced its total ban in 1998, and Nicaragua last year. In 69 countries, including many African nations, abortion is still banned except when a woman鈥檚 life is at stake. Another 57 nations monitored by CRR are restrictive, but extend the grounds for legal abortion to preserving a woman鈥檚 physical or mental health.
Meanwhile, although abortions are freely available in the US, the number of abortion providers declined by 37 per cent between 1982 and 2000, and the Bush administration has pushed its anti-abortion agenda globally through its policy of withholding family planning aid from organisations that back safe abortion 鈥� the so called 鈥済ag rule鈥�.
Ipas, a New York-based organisation that promotes women鈥檚 sexual rights, has been monitoring the rule鈥檚 effects in a number of countries, including Kenya, Zambia and Nepal, since 2001. The Family Planning Association of Kenya (FPAK) lost 58 per cent of its budget because it couldn鈥檛 agree to the terms of the rule as it offers abortion advice, says Joachim Osur, former medical director of the FPAK and senior advisor to IPAS. 鈥淚 had to close half of our 16 clinics, serving between 80,000 and 100,000 women annually,鈥� he says.
Denied adequate contraception and family planning advice, Kenyan women are now having more unsafe abortions. 鈥淥ne third of Kenya鈥檚 maternal deaths are due to unsafe abortion,鈥� says Osur.
