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Download Article 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.
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