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Trends in the Method and Gestational Age of Abortion in High-Income Countries

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Trends in the Method and Gestational Age of Abortion in High-Income Countries Review BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2018-200149 on 8 April 2019. Downloaded from Trends in the method and gestational age of abortion in high-income countries Anna Popinchalk, 1 Gilda Sedgh2 ► Additional material is ABSTRACT Key messages published online only. To view Background Examining the distribution of abortions please visit the journal online by method of abortion and gestational age at time (http:// dx. doi. org/ 10. 1136/ ► In the majority of countries, medication bmjsrh- 2018- 200149). of termination provides insight about the options (or medical) abortion accounts for at women may have to terminate their pregnancies. 1Guttmacher Institute, New York, least half of all abortions, and this has Comparing these distributions across countries New York, USA increased over the past 10 years. 2 Guttmacher Institute, New York, and over time is an important step toward ► In the majority of countries, at least 90% New York, USA understanding the factors that can drive these of abortions occur under 12 weeks, and distributions, including regulations and practices the proportion of abortions obtained Correspondence to related to the provision of abortion services, and earlier than 9 weeks has increased in most Anna Popinchalk, Guttmacher countries. Institute, New York NY 10038, women’s preferences and needs. USA; apopinchalk@ guttmacher. Methods We sought official statistics on gestational ► Findings suggest improvements in org age and method of abortion for all high-income access to timely care and a choice of countries with liberal abortion laws. For the 24 methods in some countries, although Received 6 June 2018 Revised 31 January 2019 high-income countries with available data, we research is needed to understand if the Accepted 5 February 2019 calculated percentage distributions of abortions observed distributions are a function of Published Online First by gestational age of pregnancy and method of women’s preferences or of barriers to 8 March 2019 abortion for 2017 or the most recent year for which care. data were available, and assessed trends in the preceding 10 years whenever possible. Results Medication (or medical) abortion accounts reliable abortion data, resulting in a for at least half of all abortions in the majority of unique opportunity to compare abortion http://jfprhc.bmj.com/ countries. In the majority of countries over 90% service provision across countries. Data of all abortions were completed before 13 weeks, on the method and gestational age of and more than two-thirds of abortions occurred abortion can provide insight on abortion before the first 9weeks of gestation. Over the provision within a country, including the past 10 years there has been an increase in both options women have to terminate their the proportion of abortions that were medication pregnancies. Trend data on these charac- abortions and the proportion that were obtained teristics can show whether abortion care on October 2, 2021 by guest. Protected copyright. before 9 weeks gestation. within a country has changed over time. Conclusions These findings highlight changes This review provides the first cross-na- in abortion provision in the past decade. More tional comparison of the method and research is needed to understand whether the gestational age of abortion in high-in- observed distributions are a function of women’s come countries, and of trends in these preferences or of barriers to the timing and type of characteristics over time. Comparing care they would prefer. how and when pregnancies are termi- nated across countries and over time is © Author(s) (or their an important first step toward under- employer(s)) 2019. Re-use INTRODUCTION standing the factors influencing the find- permitted under CC BY-NC. No commercial re-use. See rights Abortion is a common event in women’s ings. These factors might include service and permissions. Published by lives: in 2010–2014, an estimated regulations, provider practices and pref- BMJ. 56 million abortions occurred, and nearly erences, and women’s preferences. Such a To cite: Popinchalk A, 8 million occurred in high-income coun- review can also be used to identify depar- Sedgh G. BMJ Sex Reprod tries.1 High-income countries with liberal tures from typical patterns, and explore Health 2019;45:95–103. abortion laws often have accessible and their causes. Ultimately these data are of Popinchalk A, Sedgh G. BMJ Sex Reprod Health 2019;45:95–103. doi:10.1136/bmjsrh-2018-200149 95 Review BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2018-200149 on 8 April 2019. Downloaded from use to policymakers, programme planners and service supplemented with information from Gynuity on the providers to ensure women have access to safe, high- year mifepristone was registered.9 quality and timely abortion care. We categorised method of abortion into three types: surgical, medication (or medical) and other. It was METHODS not possible to further refine these categories due to Official statistics on the number of legal abortions by differences in abortion reporting, method availability, gestational age and method of abortion were sought for and terminology between countries. For this review the 40 high-income countries with liberal abortion laws, article, medication abortion refers to primarily the using information on countries’ abortion laws compiled regimen of mifepristone and misoprostol, although if by the Guttmacher Institute.2 We identified high-income a country reported abortions obtained through miso- countries using the World Bank country classifications by prostol alone, they were also included in the total of income level, for the year 2017.3 In conjunction with data medication abortions. In addition, the Netherlands collection on abortion incidence, we collected data from and Canada report a category of surgical abortion plus 2012 to 2018. We collected data for the most recent year medication abortion, and these abortions were classi- available after 2010, and, when possible, we also collected fied as surgical abortions. The definition of other abor- data for the 10 years prior. Countries were categorised as tion varies by country and not all countries explicitly having liberal abortion laws if abortion was legal without state what falls under this category, but it can include restriction or was legal on socioeconomic grounds, either methods such as hysterotomy. with or without gestational limits. We also include New We collated gestational age data as follows: fewer than Zealand and Israel, where abortion is allowed to preserve 9 weeks (up to 8 weeks and 6 days), 9–12 weeks, and 13 a woman’s mental health, because this ground is inter- or more weeks. These categories reflect the most common preted relatively liberally in these two countries.2 Among classification of gestational age in country reports. Coun- the 24 high-income countries for which data were avail- tries that use different classification categories are indi- able, abortion was available on request in 18 countries, on cated in the footnotes of figure 3. socioeconomic grounds in four, and for the mental health Of the 40 high-income countries with liberal laws in of the woman in two (table 1).4 the world as of 2017 (as defined by the World Bank, and To collect official abortion statistics, we searched the for countries with populations greater than one million), websites of statistical offices or relevant agencies for data were available on the method of abortion in 16 the most recent official abortion data available (online countries and on the gestational ages at which abortions supplementary supporting table 1). When the search were performed in 21 countries. In 10 countries, the data resulted in reports with data from previous years the on abortions are from 2017; in the remaining countries, data for up to 10 years prior were collated. When the most recent year for which data were available ranged data were not available online, we contacted agencies from 2011 to 2016. The year of data available for each directly and asked officials to complete a standardised country can be found in online supplementary supporting questionnaire that gathered information from official table 3. Trend data were not available for all countries, http://jfprhc.bmj.com/ records on the incidence of legally induced abortions and we present trends on the method of abortion for 11 and characteristics of abortions including gestational countries, and the gestational age for 13 countries. The age and method. This questionnaire was distributed difference between data availability for gestational age for a study on abortion incidence that began in 2014 and method is attributed to variations in what characteris- and the questionnaires requested data on abortions up tics countries collect and report in their official abortions to 2017. For the United States, we utilised results from statistics. In Great Britain, Scotland reports its abortion the Guttmacher Institute Abortion Patient Survey,5 as statistics separately from England and Wales, and the on October 2, 2021 by guest. Protected copyright. abortion statistics from the Centers for Disease Control categories used for gestational age and method differ and Prevention do not contain data for all states.6 slightly. Therefore the data for these geographic areas As the legal status and legal indications of abor- are presented separately in this analysis, but are counted tion can influence the method and gestational age of as one country in the above tabulations. In addition,
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