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Abortion Worldwide: a Decade of Uneven Progress

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Abortion Worldwide: a Decade of Uneven Progress Abortion Worldwide: A Decade of Uneven Progress Abortion Worldwide: A Decade of Uneven Progress Susheela Singh Deirdre Wulf Rubina Hussain Akinrinola Bankole Gilda Sedgh Acknowledgments Abortion Worldwide: A Decade of Uneven Progress was Junice L. Demeterio-Melgar, Likhaan (Philippines); Teresa written by Susheela Singh, Rubina Hussain, Akinrinola DePiñeres, University of California, San Francisco, and Bankole and Gilda Sedgh, all of the Guttmacher Institute, Fundación Oriéntame and Fundación Educación para la and Deirdre Wulf, independent consultant. The report was Salud Reproductiva (USA and Colombia); Fariyal Fikree edited by Peter Doskoch and copyedited by Haley Ball; and Rhonda Smith, Population Reference Bureau (USA); Kathleen Randall supervised production. Beth Fredrick, formerly of the International Women’s Health Coalition (USA); Aurélie Gal and Serge Rabier, The authors thank the following colleagues for their com- Équilibres et Populations (France); Sandra Garcia, ments and help in developing this report: Elena Prada and Population Council (Mexico); Agnès Guillaume, Institut Michael Vlassoff, for reviewing the literature; Alison National d’Études Démographiques–Institut de Recherche Gemmill, for providing research support throughout the pour le Développement (France); Ana Langer, project; and Ann Biddlecom, Sharon Camp, Susan A. EngenderHealth (USA); Katarina Lindahl, Lars Olsson, Cohen, Leila Darabi, Patricia Donovan, Stanley K. Christina Rogala and Ann Svensén, Swedish Association Henshaw, Ann Moore, Cory L. Richards and Gustavo for Sexuality Education (Sweden); Roland Edgar Mhlanga, Suárez, for reviewing drafts of the report. Special thanks Nelson Mandela School of Medicine (South Africa); Joana are due to Jacqueline E. Darroch and Stanley Henshaw Nerquaye-Tetteh, Planned Parenthood Association of for assistance with data interpretation and to Evert Ghana (retired; Ghana); Friday Okonofua, Women’s Ketting for providing data from various European coun- Health Action and Resource Centre (Nigeria); Boniface tries. All are affiliated with the Guttmacher Institute, Oye-Adeniran, Campaign Against Unwanted Pregnancy except for Elena Prada and Evert Ketting, who are inde- (Nigeria); Ndola Prata, University of California, Berkeley pendent consultants. (USA); Clémentine Rossier, Institut National d’Études The authors are grateful for the suggestions and advice Démographiques (France) and Institut Supérieur des offered by the following colleagues, who reviewed the Sciences de la Population (Burkina Faso); Florina entire manuscript: Elisabeth Åhman and Iqbal Shah, Serbanescu, Centers for Disease Control and Prevention World Health Organization (Switzerland); Paschal Awah, (USA); Mary Shallenberger, American Leadership Forum Janie Benson, Eunice Brookman-Amissah and Merrill (USA); Iwu Utomo, Australian National University Wolf, Ipas (USA, Cameroon and Kenya); Hedia Belhadj, (Indonesia and Australia); and Beverly Winikoff, Gynuity United Nations Population Fund (USA); Kelly Blanchard, (USA). Ibis Reproductive Health (USA); Reed Boland, Harvard The Guttmacher Institute gratefully acknowledges the School of Public Health (USA); Tania Boler, Marie Stopes general support it receives from individuals and founda- International (United Kingdom); Luisa Cabal and Laura tions—including major grants from The William and Flora Katzive, Center for Reproductive Rights (USA); Giselle Hewlett Foundation, the David and Lucille Packard Carino and Carrie Tatum, International Planned Foundation, the Ford Foundation and others—which Parenthood Federation, Western Hemisphere Region undergirds all of the Institute’s work. (USA); Rebecca Cook, University of Toronto (Canada); Abortion Worldwide: A Decade of Uneven Progress2 Guttmacher Institute Table of Contents Executive Summary 4 Chapter 1: Abortion Worldwide: What Has Changed? 6 Chapter 2: Women Around the World Live with Widely Varying Abortion Laws and Services 9 Chapter 3: Abortion Rates Have Fallen, but Unsafe Abortion Rates Have Not 16 Chapter 4: Safe Abortion Services Are Delivered in Many Ways 20 Chapter 5: When Abortion Laws Are Restrictive, Women Are At Risk for Unsafe Abortion 25 Chapter 6: Quality Postabortion Care Can Reduce the Harmful Effects of Unsafe Abortion 30 Chapter 7: Preventing Unintended Pregnancy Is Fundamental To Reducing Abortion 37 Chapter 8: Conclusions and Recommendations 44 Appendix Tables 50 Data and Methods Appendix 56 References 59 Guttmacher Institute3 Abortion Worldwide: A Decade of Uneven Progress Executive Summary his report assesses progress over the past decade ened, and in three cases the criteria were narrowed. regarding the legality, safety and accessibility of Nonetheless, especially in Sub-Saharan Africa and Latin abortion services worldwide. It summarizes devel- America, abortion remains highly restricted. opments in policy and documents recent trends in T I Globally, 40% of women of childbearing age (15–44) live abortion incidence, with a focus on unsafe abortion. It in countries with highly restrictive laws (those that pro- also examines the relationship between unintended preg- hibit abortion altogether, or allow the procedure only to nancy, contraception and abortion, placing abortion with- save a woman’s life, or protect her physical or mental in the broader context of women’s reproductive lives. health). Positive trends have emerged in recent years I Virtually all countries with highly restrictive laws are developing countries. Excluding those in China and Significant global changes that have occurred in the past India (populous countries with liberal abortion laws), decade have important implications both for the levels and 86% of reproductive-age women in the developing world safety of abortion and for the levels of unintended preg- live under highly restrictive abortion laws. nancy, the root cause of abortion. I In some countries (e.g., India and South Africa), abor- I Contraceptive use, which reduces levels of unintended pregnancy, has increased in many parts of the world, tion is available on broad grounds, but access to ser- particularly Latin America and Asia. vices provided by qualified personnel is uneven. I The use of manual vacuum aspiration (MVA) and of medication abortion to end unwanted pregnancies and Abortion rates have declined worldwide to treat unsafe abortion have increased. The overall abortion rate declined between 1995 and 2003. This is largely due to reductions in levels of safe I A number of countries in which abortion laws were high- abortions, particularly in Eastern Europe. ly restrictive in the mid-1990s have liberalized their laws. I The number of abortions worldwide fell from an estimat- I In many developing countries in which abortion is legally ed 45.5 million in 1995 to 41.6 million in 2003. The esti- restricted, access to safe abortion nevertheless appears mated number of unsafe abortions changed little during to be growing, especially for better-off women. this period—from 19.9 million to 19.7 million—and almost all occurred in developing countries. Although some countries have liberalized their I The rate of safe abortions dropped between 1995 and laws, abortion remains highly restricted 2003 from 20 to 15 per 1,000 women aged 15–44, while Since 1997, 22 countries or administrative areas within the unsafe abortion rate declined hardly at all—from 15 countries have changed their abortion laws; in 19 cases, to 14 per 1,000. The overall abortion rate declined from the criteria under which abortion is permitted were broad- 35 to 29 per 1,000. Abortion Worldwide: A Decade of Uneven Progress4 Guttmacher Institute Women in developing countries with restrictive Some important challenges remain abortion laws often go to untrained providers Many obstacles to safe and legal abortion, and to adequate Surveys of knowledgeable health professionals in develop- contraceptive and postabortion care, remain. ing countries with highly restrictive abortions laws have I Legal reform can take many years to achieve. Impedi- provided information about the circumstances surround- ments include the persistence of outmoded laws, opposi- ing unsafe abortions. tion from powerful religious authorities, the activities of I Women who seek clandestine abortions most commonly antichoice groups and reluctance to publicly address go to traditional practitioners (many of whom employ sensitive issues of sexuality and reproduction. unsafe techniques), or doctors or nurses (who may have I Procedural, economic, informational, cultural and other inadequate training). Some women try to self-induce barriers continue to impede access to legal abortion (using highly dangerous methods), or go to pharmacists services in many developing countries. or other vendors to purchase drugs. I Access to contraceptive and postabortion services is often I Rural women and poor women are more likely than inadequate, partly because of insufficient resources. better-off and urban women to turn to traditional prac- titioners and unsafe methods, and therefore to experi- ence health complications. However, they are less likely What must be done to reduce unsafe abortion to receive the postabortion treatment they need. and its consequences? There are three known ways to reduce the prevalence of I The severity of complications from unsafe abortion is probably declining. Contributing factors include the unsafe abortion and its harmful consequences. spread of medication abortion (especially the use of I Expanding access to effective modern methods of con- misoprostol alone)
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