Gut tmacher Policy Review Fall 2012 | Volume 15 | Number 4 GPR
Access to Safe Abortion in the Developing World: Saving Lives While Advancing Rights
By Susan A. Cohen
t the London Summit on Family Global Abortion Rate Plateaus Planning earlier this year, donor and According to a 2012 analysis by the Guttmacher recipient country governments, phar- Institute and the World Health Organization Amaceutical companies and civil society (WHO), what had been a downward trajectory in organizations from around the world made the worldwide abortion rate over the last couple substantial new commitments toward the goal of of decades—which was accompanied by increas- significantly reducing the unmet need for contra- ing contraceptive use rates—has now stalled.1 ception by 2020. These promises, if kept, will go Moreover, abortion is becoming increasingly con- a long way toward also reducing the number of centrated within the developing world; the vast abortions that take place each year in the devel- majority of abortions take place in the world’s oping world, but they cannot make the reality of poorest countries. And it is in these countries abortion go away. where abortion is most often clandestine and un- safe (see chart). Levels of unintended pregnancy vary across soci- eties and over time; however, because no revers- The new study also reconfirms a longtime truth: ible method of birth control is perfect and few that the frequency of abortion has much less to human beings use methods perfectly, women do with its legal status than with levels of unin- will always experience unintended pregnancies. tended pregnancy. Unintended pregnancy levels, Thus, there will always be a need for abortion, in turn, are influenced primarily by levels of mod- and for safe abortion services. Tragically, of the ern contraceptive use. roughly 44 million abortions that take place glob- ally each year, a rising proportion—now about Europe, which has both the lowest and highest half—are medically unsafe.1 Virtually all unsafe abortion rates in the world, illustrates this truth. abortions occur in developing countries, taking a The lowest rates can be found in countries in devastating toll on women’s health and lives. Western Europe, where the average rate for the subregion is 12 per 1,000 women aged 15–44; the Reducing the incidence of unsafe abortion highest rates are in Eastern Europe, averaging 43 remains an urgent public health imperative. per 1,000. Abortion is broadly legal in both sub- Beyond that, however, there is a growing recog- regions. Levels of effective contraceptive use and nition at the global level and within developing unintended pregnancy, however, are radically countries that access to comprehensive repro- different. In Western Europe, correct and consis- ductive health services must include access to tent use of modern contraceptives is high and abortion—and that removing legal barriers to unintended pregnancy rates are low, whereas the abortion not only protects women’s health, but opposite is true in Eastern Europe. restores their dignity and vindicates their basic human rights. The average abortion rate across the countries of the former Soviet Union—90 per 1,000 women—
2 was among the highest in the world in 1995.1 galization can make to the safety of abortion. It During the Cold War, modern contraceptives also proves that legalization alone is not enough. simply were not available in these countries; Additional steps must follow: medical training abortion was the method available to women that can take place aboveboard, appropriate for controlling births. The advent of modern con- health and safety standards for clinical settings traceptives in these countries in the early 1990s that can be established and enforced, information began to drive the abortion rate down sharply and referrals that can be made widely available to where it is now. The transition from primary to facilitate timely access to care, and costs that reliance on abortion to contraceptive use as the can be established not subject to extortion and means of controlling births is still a work in prog- that may be covered by public or private health ress in Eastern Europe. Whether the momentum insurance. Not nearly enough progress has oc- continues will depend on the supply of quality curred in South Africa to make safe abortion care and effective methods, proper training of health there universal. Yet, even under imperfect condi- care providers, the cost of services and adequate tions, abortion-related deaths in South Africa information for women about their choices. plummeted by as much as 90% in the years fol- Already, however, the experience in Eastern Europe demonstrates unequivocally the effective- ness of contraceptive use in reducing unintended COMMON AND CLANDESTINE pregnancy and recourse to abortion. Most of the world’s 44 million abortions occur in the developing world… In regions of the developing world where contra- ceptive use is relatively low, the average abortion 7% 7% rates cluster much more closely to the levels in Eastern Europe than in Western Europe. Unlike in Eastern Europe, however, abortion in Sub- Saharan Africa, Latin America and parts of Asia is mostly illegal, clandestine and unsafe. 21% 65%
The Health Rationale In some countries where abortion is legal—India is a prime example—medically unsafe abortion is still widespread, because too many women Developing China Eastern Europe Developed remain unaware of the law and cannot surmount countries countries the many cultural, financial and geographic ob- stacles to obtaining services under sanitary con- …where abortion is often clandestine and unsafe. ditions from medical professionals.2 Conversely, even where1.0 abortion is illegal, it is often true that at least more affluent women are able to obtain 97% 95% safe, if still0.8 underground, abortion services. Mainly, however, the evidence is consistent and compelling0.6 that where abortion is legal, it is Developed countries much more likely to be safe, and where it is il- legal, unsafe.0.4 Antiabortion advocates are often Eastern Europe 40% quick to point out the few exceptions to this gen- China eral rule, 0.2but the fact remains that the countries in this category are outliers for some very spe- cific reasons0.0 (see box, page 4). Africa Latin America Asia (including China) % of abortions that are unsafe South Africa, which legalized abortion in 1997, Note: Developed countries include Australia, New Zealand, Japan and those is a textbook example of the difference that le- in Western Europe and North America. Source: reference 1.
Guttmacher Policy Review | Volume 15, Number 4 | Fall 2012 3 Abortion Legality, Safety and Maternal Mortality: The Outliers Around the world, where abortion is Some countries in Latin America much lower risks of severe health con- highly restricted, it is not necessarily also do not fit the pattern. Abortion is sequences than illegal surgical proce- less common than elsewhere, but is al- banned outright in Chile, for example, dures. Finally, Chile’s advanced health most always less safe—and this is re- but the maternal mortality rate of 25 care system enables women who pres- flected in country levels of pregnancy- pregnancy-related deaths per 100,000 ent themselves in hospital emergency related death and disability. Of course, live births is relatively low compared rooms to receive effective treatment there are a few countries that do not fit with the rest of South America. In this for postabortion complications, thereby this mold, and they tend to share cer- case, it is noteworthy that since the greatly reducing the harms of unsafe tain characteristics. 1960s, access to and use of modern abortion. contraceptives in Chile has improved According to WHO, pregnancy-related Two new studies looking at improve- greatly, leading to declines in unin- death is very rare in Ireland and Malta, ments in abortion complication rates in tended pregnancy, unsafe abortion for example, yet abortion is entirely Brazil (where abortion is mostly illegal) and abortion-related hospitalizations.4 illegal in both countries. By no means and Colombia (which liberalized its Moreover, an increasing proportion does this mean that women in these law in 2006, but where access to safe of the clandestine abortions that do countries never have abortions. Travel services is still scarce) also conclude occur result from women’s use of across borders is relatively easy in that increased reliance on misoprostol misoprostol—a safe, low-cost, legal Europe, so women do not need to re- is a significant contributor.5,6 In all these and widely available over-the-counter sort to clandestine, unsafe abortion, countries, however, safer forms of clan- drug (commonly used to prevent post- because they can and do go to nearby destine abortion and better treatment partum hemorrhage) that can be used countries for safe abortion services or of the complications of inadequate to induce abortion without surgery. The postabortion care. This phenomenon abortion care can only mitigate—not use of misoprostol as an abortifacient has been studied extensively in Ireland, eliminate—the risks to women’s health has been widely promoted by women’s where it is well-established that thou- where abortion is illegal and access to rights advocates in Chile since the sands of women travel to England each medically safe services is limited. 1990s, because it is associated with year to obtain safe abortion care.3
lowing legalization.7 Similarly, improved health highly restrictive laws. Another eight million outcomes for women are already becoming ap- women suffer serious and sometimes permanent parent in Ethiopia and Nepal, both of which legal- injury as a result of complications from medically ized abortion only within the last decade.8 unsafe abortion.9
Where abortion is legal, safe and accessible, and The impact of unsafe abortion can be lessened to as the many cultural barriers to care fall away, some extent by better access to treatment for the incomplete or septic abortion is far less likely, complications of unsafe abortion. However, this and so is the suffering and death that too often assumes the presence of adequate health sys- ensues. According to WHO, unsafe abortion tems and a woman’s ability to endure the stigma remains one of the four leading causes of preg- she is likely to face when she presents at a hos- nancy-related death and injury around the world, pital with hemorrhage or infection resulting from along with hemorrhage, infection and high blood an illegal abortion. In addition, particularly in pressure in connection with childbirth. Although Latin America, the severity of the complications great improvements have been seen recently in from unsafe abortion is starting to decline signifi- the global maternal mortality rate, the proportion cantly as more women rely on misoprostol. of deaths attributable to unsafe abortion is hold- ing steady at 13%. This translates to 47,000 deaths Women and their families pay the main price each year, almost all occurring in countries with of unsafe abortion, but countries pay as well, in
4 Fall 2012 | Volume 15, Number 4 | Guttmacher Policy Review terms of productive lives lost and dollars. A new forced contraception and forced pregnancy has analysis from Ethiopia presents the first com- long been recognized as an unjustifiable form of prehensive look at the true cost to the national State-sanctioned coercion and a violation of the health system of providing postabortion care.10 right to health.” Likewise, he concludes, “where It found that the direct cost of treating postabor- the criminal law is used as a tool by the State to tion complications in 2008 was $7.6 million, or regulate the conduct and decision-making of in- $36 per woman treated. This, in a country where dividuals in the context of the right to sexual and the average person lives on less than one dollar a reproductive health the State coercively substi- day. Although Ethiopia legalized abortion in 2006, tutes its will for that of the individual.” only one-quarter of all abortions in 2008 were performed under safe conditions. The study’s Grover’s report is groundbreaking because it authors calculated that the costs of postabortion represents the first time an official report of the care could be slashed by ramping up investment UN makes the case that laws criminalizing abor- in contraceptive services: Each additional dol- tion or otherwise limiting its access or access to lar invested in family planning would save an contraceptive services infringe women’s human estimated $6 in costs currently going toward the rights. “Criminal laws and other legal restrictions treatment of postabortion complications. on sexual and reproductive health may have a negative impact on the right to health in many The Human Rights Lens ways, including by interfering with human dig- Clearly, the consequences of unsafe abortion can nity,” Grover writes. “Respect for dignity is fun- be reduced through better treatment and less damental to the realization of all human rights. unsafe methods. And the number of abortions Dignity requires that individuals are free to make can be decreased by preventing more unintended personal decisions without interference from the pregnancies through greater access to quality State, especially in an area as important and inti- family planning services. For those abortions that mate as sexual and reproductive health.” will always be necessary, however, unsafe ser- vices must be replaced by safe services, for the Earlier this year, WHO picked up this theme sake of women’s health and lives. Further, gov- and incorporated it into its new edition of Safe ernments have an obligation to remove criminal Abortion: Technical and Policy Guidance for or other legal barriers to services, so that this key Health Systems.12 This important report assesses aspect of the global human right to health can and synthesizes the state of the research and evi- be fully realized—as now recognized by a 2011 dence on abortion, and makes recommendations report by the United Nations (UN) Human Rights for clinicians, program managers and policymak- Council Special Rapporteur and more recently by ers regarding abortion-related care. For the first WHO.11,12 time, WHO devotes considerable attention to articulating a rights-based framework for making The UN Human Rights Council appointed Anand abortion safe and truly accessible. Drawing on Grover as its Special Rapporteur on the right to Grover’s analysis, the WHO report identifies the health in 2008. A prominent human rights lawyer numerous international treaties and agreements in India with a long history working on issues that provide a legal basis for its conclusions. It relating to HIV and AIDS at the national and inter- summarizes the large body of research over the national levels, Grover has researched, analyzed years demonstrating that making abortion illegal and made recommendations to the council on a or difficult to obtain has a much greater impact variety of health topics utilizing a human rights on safety than on incidence. WHO notes that nu- framework. In his 2011 report, Grover equates the merous UN treaty-monitoring bodies call for en- offense of forced abortion with forced pregnancy suring legal abortion at least in cases where the and condemns governments for their complic- woman’s life or health would be endangered by ity.11 He asserts that “the use of overt physical continuing the pregnancy or in the event of rape coercion by the State or non-State actors, such as or incest. (Notably, six in 10 of the more than 700 in cases of forced sterilization, forced abortion, million women living in developing countries
Guttmacher Policy Review | Volume 15, Number 4 | Fall 2012 5 other than China and India live where abortion REFERENCES is completely banned or legal only to save a 1. Sedgh G et al., Induced abortion: incidence and trends worldwide 2 from 1995 to 2008, Lancet, 2012, 379(9816):625–632,
6 Fall 2012 | Volume 15, Number 4 | Guttmacher Policy Review