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Guttmacher Policy Review Fall 2009 | Volume 12 | Number 4 GPR

Facts and Consequences: Legality, Incidence and Safety of Worldwide

By Susan A. Cohen

round the world, according to a new tended —by expanding access to con- Guttmacher Institute report, Abortion traceptive information and services. Worldwide: A Decade of Uneven AProgress, as contraceptive use contin- Illegal Abortion Is Usually ues to increase, levels of unintended pregnancy Throughout , except for Ireland and and abortion are declining. Of the approximately , abortion is broadly legal, widely avail- 42 million that do occur worldwide, able and safe.The legalized abor- almost half are performed by unskilled individu- tion nationwide in 1973, in part because of the als, in environments that do not meet minimum clear evidence that restrictive were not medical standards or both. Virtually all of these ending abortion but were exacting a significant unsafe abortions take place in the developing public health toll, notably on lower-income world, where the unmet need for contraception women who could not travel or pay for safe remains high and very restrictive abortion laws services. Almost immediately afterward, preg- often are the norm. nancy-related and hospitalizations due to complications of unsafe abortion effectively In the developed and developing world alike, ended.The United States was not the first coun- antiabortion advocates and policymakers refuse try and has been far from the last to recognize to acknowledge the facts that abortion’s legal this relationship and move to liberalize its . status has much less to do with how often it occurs than with whether or not it is safe, and was the first large developing country to that the surest way to actually reduce the inci- enact a liberal abortion law—in 1957.The Soviet dence of abortion is to reduce the incidence of Union and the central and western Asian republics unintended pregnancy. While they debate, obfus- enacted similar laws in the 1950s. Over the next cate and insist on legal prohibitions, the conse- 50 years, abortion become legal on broad quences for women, their families and society as grounds in a wide range of less developed coun- a whole continue to be severe and undeniable. tries, including (1965), (1970), (1971), (1972), (1973), The lack of qualified medical providers, the (1975), (1983), (1985), stigma associated with illegal abortion, poor (1989), South (1996) and (1997). health systems and grinding poverty all con- Indeed, the worldwide trend in abortion law has tribute to the high health risks and to the social continued to be toward liberalization. And since and financial costs of unsafe abortion.The public 1997, another 21 countries or populous jurisdic- health tragedy caused by unsafe abortion is all tions have liberalized their laws, including the more so because it is largely preventable, by , , , City, improving the quality and availability of andThailand. During this same period, postabortion care, by making abortion legal and only three countries—, and increasing access to safe services, and—because Poland—have increased restrictions. almost every abortion is preceded by an unin-

2 Today, 60% of the world’s 1.55 billion women of hour. Approximately eight million more women reproductive age (15–44) live in countries where per year suffer postabortion complications that abortion is broadly legal. can lead to short- or long-term consequences, including anemia, prolonged weakness, chronic The remaining 40% live where abortion is highly inflammation of the reproductive tract and sec- restricted, virtually all in the developing world. In ondary infertility. Of the women who experience Africa, 92% of women of reproductive age live serious complications each year, nearly three under severely restrictive laws; in , million never receive treatment. 97% do. Ironically, the abortion laws governing most of the countries in these regions are Restrictive laws have much less impact on stop- holdovers from the colonial era, imposed by ping women from ending an unwanted preg- European countries that have long ago aban- nancy than on forcing those who are determined doned such restrictive laws for themselves. to do so to seek out clandestine means. In coun- tries with such restrictive laws, women who can In a country such as , about 300,000 pay can sometimes find a qualified provider will- abortions take place each year, notwithstanding ing to perform an abortion; however, the vast the fact that abortion is legal only to save a majority of women in poor countries are too woman’s life. Unsafe abortion there is a leading poor to avail themselves of this underground cause of pregnancy-related . Moreover, at network. In , for example, where 37% current rates, half of all Ugandan women will of the population lives on less than $2 a day, the require treatment for complications related to estimated cost of an illegal abortion carried out abortion at some point in their lives. by a private medical doctor or in a private med- ical clinic ranges between $128 and $1,026. In The Heavy Toll of Unsafe Abortion Uganda, where 97% live on less than $2 a day, The fact is that almost all unsafe abortions occur the price of an abortion from a professional in the developing world (see chart). According to source is $6–58. And in , 66% live on less the World Health Organization, unsafe abortion is than $2 a day, and the average fee for a doctor- the cause of 70,000 maternal deaths each year— assisted abortion is $50–104. or one in eight pregnancy-related deaths among women.That translates to seven women per The measurable effect of these economic reali- ties, which relate directly to the secrecy and stigma attached to abortion where the law and UNSAFEABORTIONS culture are disapproving, shows up in the high Of the almost 42 million abortions that take place around the world rates of death and disability that women suffer each year, about 20 million are unsafe and virtually all of those occur in from taking the decision into their own hands. developing countries. Women themselves or untrained providers use a variety of traditional and often dangerous meth- World 21.9 19.7 41.6 ods to end an unwanted pregnancy, such as inserting sticks into the vagina, drinking bleach or applying extreme pressure to the abdomen, which often result in severe complications, such Less developed 15.8 19.2 35.0 as hemorrhage. Fear of being discovered break- ing the law or being accused of promiscuity causes many women to choose secrecy over their More developed 6.1 6.6 own safety.The shaming and blaming of women who have abortions in many of these cultures is an impediment to their seeking out the necessary 0 10 20 30 40 50 postabortion medical care to save their lives. Millions of abortions, 2003

Safe Unsafe About 40% of women who have a clandestine Source: Guttmacher Institute, 2009. abortion experience complications that require

Guttmacher Policy Review | Volume 12, Number 4 | Fall 2009 3 treatment.Yet, even if a woman makes it to a med- soon after abortion was legalized in 2004, the ical facility, too many health centers in developing number of women admitted for complications of countries simply do not have the capacity to unsafe abortion and the severity of those compli- deliver quality care for the complications resulting cations declined markedly; pregnancy-related from an unsafe abortion. Health systems in these deaths in Nepal also declined. countries are usually strained and inadequate to begin with. However, the weak infrastructure is Changing the law is only the beginning, how- often further compounded by a lack of trained per- ever, and by itself is no guarantee that unsafe sonnel and supplies, as well as judgmental or abortion will cease to exist. For example, abor- punitive attitudes among staff toward women tion has been legal in Zambia since 1994. seeking postabortion treatment. Even contracep- However, safe services remain out of reach for tive counseling to help women avoid a future most women there for several reasons:There is unwanted pregnancy is often unavailable: Studies only one doctor per 8,000 individuals, a woman of women treated for complications of clandestine seeking an abortion must obtain the consent of abortion in the , and a three physicians, many doctors will not perform poor southern state in Mexico found that women abortions for religious or moral reasons and, in often left without a contraceptive method. the few hospitals where legal abortions are avail- able, the cost is prohibitive. And in India, where The costs in women’s lives and health because of abortion has been legal for more than 30 years, unsafe abortion are a human tragedy, but there about three unsafe abortions take place for every are also costs to society.To provide care for the two safe procedures. Most women cannot afford illness and disability associated with unsafe abor- to pay private-sector prices, so they go to public tion, a government spends, on average, at least health facilities where quality of care is poor. $114 per case in Africa and $130 in Latin America; Physician training is often inadequate, sanitary in these regions, the total per capita spending on medical conditions are lacking, and privacy and health care is $48 and $329, respectively. confidentiality are often compromised. Moreover, authorized abortion facilities in India Each year, an estimated five million women are routinely turn a woman away if she arrives hospitalized for the treatment of abortion compli- alone, is unmarried or is married but childless. cations, at a cost of at least $460 million. However, even in countries with highly restric- Therefore, even after legalization, more hurdles tive laws, these high financial burdens can be remain. Providers must be willing to step up and avoided or at least reduced through prevention. receive training. Safe services in hygienic condi- According to a case study in , for exam- tions must be made widely available and afford- ple, the cost of providing contraceptive services able. And then, the even longer process of to enable women to avoid the unintended preg- changing cultural attitudes can begin, so that the nancies that end in unsafe abortion would be stigma associated with providing and obtaining only one-quarter of what Nigerian health facili- abortions can lessen and safe services can ties spend to provide postabortion care. become normal and accepted.

Toward Legality and Safety Making Abortion Less Likely As more developing countries have reformed Between 1995 and 2003, the global abortion rate their abortion laws, new evidence is accumulat- dropped by 17%. Africa and Asia saw a 12% ing that legal abortion saves women’s lives. By decline during the same period, and Latin 2002 in , for example, six years after America and the Caribbean experienced a drop liberalizing its abortion law, deaths due to unsafe of 16%. In Eastern Europe, though, the abortion abortion dropped by at least 50% and the rate plummeted by 51%. Notably, the largest number and severity of postabortion complica- decline occurred in the former Soviet bloc coun- tions fell dramatically as well. Similarly, accord- tries, where abortion has been legal the longest ing to Nepalese government hospitals records, and is widely available.

4 Fall 2009 | Volume 12, Number 4 | Guttmacher Policy Review Clearly, it is not the changes in abortion’s legal CONTRACEPTIVEUSE status that can explain the decreased abortion In all regions of the world, contraceptive use is on the rise, but it still rate worldwide, since many more countries liber- remains extremely low in Africa. alized access to abortion than restricted it.

Significantly, though, during this same period, 17 contraceptive use worldwide increased and unin- Africa 28 tended pregnancy rates fell. Where contraceptive use increased the most, abortion rates dropped 57 the most. Contraceptive use has increased glob- Asia 68 ally and in every region of the world, but it remains extremely low in Africa (see chart). Not 62 Latin America surprisingly, therefore, the world’s highest levels 71 of unintended pregnancy can be found in Africa—86 per 1,000 women aged 15–44, almost 66 Europe three times the rate in western Europe. Indeed, 68 the 26% of women in developing countries who are at risk of unintended pregnancy but do not 71 North America practice contraception or use only traditional 72 methods account for 82% of the 75 million unin- 0 20 40 60 80 100 tended that occur each year. % of married women aged 15–49 practicing contraception

1990 circa 2003 Where contraceptive use is high, abortion can be legal and widely available, and still relatively Source: Guttmacher Institute, 2009. rare.The lowest abortion rates in the world can be found in western and northern Europe, where ductive health programs overseas, but according abortion has been legal for decades but access to its commitments at the ICPD and the large to contraception is widespread. In the United unmet need for services, the United States States, the story is similar. In 1973, right after should be providing at least $1 billion annually in abortion was legalized nationwide, the U.S. abor- aid—about twice the level it is allocating now. tion rate increased somewhat as safe legal abor- Increasing access to contraceptive services is at tions replaced unsafe illegal ones.The rate the core of the U.S. program. As such, the United peaked in 1981 and has been on a steady decline States is making a significant contribution toward since then to 19 per 1,000 women aged 15–44 reducing the need for abortion altogether and the today, its lowest level since 1974. likelihood of unsafe abortion by bringing down the rates of unintended pregnancy. Promises to Keep All governments—donor and recipient countries The United States is also helping to reduce com- alike—can do much more to save women’s lives, plications of unsafe abortion through its support and to protect and promote their health. Indeed, for programs to increase access to and improve virtually every government promised to do so at postabortion care.This includes not only treat- the 1994 International Conference on Population ment for septic or incomplete abortion, but also and Development (ICPD) in Cairo and at the 1995 essential postabortion family planning counsel- Fourth World Conference on Women in Beijing. ing and services to lessen the chances of another Almost all the world’s governments are commit- unintended pregnancy.The U.S. Agency for ted to achieving the Millennium Development International Development itself recently Goals by 2015, which also include a call for uni- affirmed its commitment to these life-saving versal access to reproductive health services. interventions (see box, page 6).

The United States has been and remains the No U.S. funds may be used to pay for the provi- single largest donor to family planning and repro- sion of abortion services, however, because of

Guttmacher Policy Review | Volume 12, Number 4 | Fall 2009 5 Postabortion Care Must Include Family Planning

Leading up to this year’s triennial for post abortion complications is and ICN, to assume an advocacy world congress of the International there because she could not get con- role to improve health outcomes for Federation of Gynecology and traception, we have failed her. If she women by providing quality Obstetrics (FIGO) in Capetown, South leaves without family planning, we postabortion family planning Africa, FIGO along with the have failed her twice.” services. International Confederation of The consensus statement calls for The statement notes the large propor- Midwives (ICM), the International several key interventions to improve tion of pregnancies worldwide that Council of Nurses (ICN) and the U.S. postabortion care. They include: end in abortion—spontaneous or Agency for International induced—and that some women who Development produced a joint state- • providing a wide range of contra- have just had an abortion are at risk ment on September 25 calling atten- ceptive methods, accompanied by of a repeat unintended pregnancy as tion to the critical importance of simple written information; early as 2–3 weeks later. Accordingly, postabortion family planning informa- • ensuring that postabortion family access to high-quality family planning tion and services. The rationale for planning is the standard of care for information and services can make a the statement is summarized in a doctors, nurses and midwives; and significant difference in reducing the quote from a meeting on postabortion likelihood of another unintended preg- care that took place during the 1994 • encouraging health professionals, nancy and abortion, safe or unsafe. ICPD in Cairo: “If the woman we treat especially members of FIGO, ICM

the 1973 law known as the Helms amendment. and to women; and enhancing life-saving This puts the United States at odds with most postabortion care. In addition, where abortion is other donor governments, which do fund the full illegal and maternal mortality is high, “DFID will range of sexual and reproductive health care, make the consequences of unsafe abortion more including safe abortion services. In fact, in widely understood, and will consider supporting October, the ’s Department for processes of legal and policy reform.” International Development (DFID) updated its policy on abortion. “DFID supports safe abortion As for the U.S. responsibility, because of its his- on two grounds,” according to the new policy. toric leadership role in this field globally—and “First, it is a right. Women have the right to now unencumbered by counterproductive policies reproductive health choices. Second, it is neces- such as the policy (also known as the sary.”This is the case because one-fifth of all global gag rule)—the United States needs to ramp pregnancies worldwide end in abortion and with- up further its financial commitment to help out access to safe abortion services, women will women in the developing world prevent unin- continue to resort to unsafe procedures. tended pregnancy. It can do more to help mitigate the consequences of unsafe abortion, including Britain’s International Development Minister, the likelihood of repeat unsafe abortion. And even Mike Foster, emphasized in a statement that within the confines of the Helms amendment, the “better access to family planning information United States can and should support abortion in and contraception is of vital importance,” but it is cases necessary to save a woman’s life and in not enough.To that end, DFID will give even instances of or . Until the Helms greater support to such activities as training in amendment is repealed altogether, the fact safe abortion techniques, including the provision remains ever clearer that it only consigns more of services; improving the con- women to needless death and disability, and has ditions under which abortions are provided and no impact on making abortion less likely. the quality of services; increasing the informa- www.guttmacher.org tion and education provided to health personnel

6 Fall 2009 | Volume 12, Number 4 | Guttmacher Policy Review