Advancing Sexual and Reproductive Health and Rights
 
The Guttmacher Report on Public Policy
October 2003, Volume 6, Number 4
 
Special Analysis

Contraceptive Use Is Key to Reducing Abortion Worldwide

By Amy Deschner and Susan A. Cohen
In countries around the world, women who are determined to limit their family size and time their childbearing will use all available means to do so; if contraception is not a viable option, women will turn to abortion—even if it is illegal. Extensive evidence demonstrates, however, that when modern contraceptives are made available to women, their increased use over time replaces previous reliance on abortion and becomes the major factor associated with reduced abortion rates. Policymakers seeking to reduce the incidence of abortion would do well to address its root cause—unintended pregnancy—by facilitating widespread access to modern contraceptives and by promoting their effective use.

This past summer, the government of Russia issued new regulations restricting the availability of legal abortions in response to the country's high abortion rate. Indeed, Russia's abortion rate is among the world's highest, although it is less than half of what it was little more than a decade ago. Between then and now, while the incidence of abortion was dropping, there was no change in the legal status of abortion. Rather, as modern contraceptives became available in the early 1990s, contraceptive use among Russian women increased sharply.

It is ironic that Russian policymakers are now leaping to a legal fix to reduce the abortion rate, considering that large numbers of Russian women have already stopped relying on abortion for birth control and, instead, have begun practicing contraception. The Russian response, however, may be just the latest example of an apparently universal political reflex: use restrictive laws to drive down the incidence of abortion rather than address its underlying cause.

Abortion Legality and Incidence

Throughout history, abortion's legal status has rarely been a reliable predictor of whether and the extent to which it occurs. Before abortion became legal throughout the United States in 1973, an estimated 200,000-1.2 million procedures occurred annually ("Lessons from Before Roe: Will Past Be Prologue?" TGR, March 2003, page 8). But it is not necessary to look back into U.S. history to discover that legal restrictions have little impact on whether women have abortions. Today, in countries around the world, large numbers of women have abortions even where the procedure is illicit and often unsafe.

Abortion is prohibited in almost all circumstances in Chile and Peru, for example, yet clandestine abortion is common. Indeed, illegal abortion in these countries is estimated to occur more than twice as often as legal abortion does in the United States (see table). And the story is similar in other Latin American countries and elsewhere. In Nigeria and the Philippines, abortion is banned, and strong conservative religious and cultural traditions would seem to militate against women resorting to abortion. Yet, the abortion rate in both countries is estimated to be 25 per 1,000 women of reproductive age—slightly higher than the U.S. rate.

ABORTION LAWS AND RATES
Country Abortion rate per 1,000 women, 15-44
Where abortion Is Broadly Permitted
Belgium, 1996* 7
England/Wales, 1996 16
Finland, 1996 10
Germany, 1996 8
Netherlands, 1996 7
United States, 1996/2000† 23/21
Where Abortion Is Severely Restricted
Brazil, 1991 41
Chile, 1990 50
Colombia, 1989 36
Dominican Republic, 1990 47
Mexico, 1990 25
Nigeria, 1996 25
Peru, 1989 56
Philippines, 1994 25
*Includes abortions obtained in the Netherlands. †Finer LB and Henshaw SK, Abortion incidence and services in the United States in 2000, Perspectives on Sexual and Reproductive Health, 2003, 35(1): 6-15. Source: Henshaw SK, Singh S and Haas T, The incidence of abortion worldwide, International Family Planning Perspectives, 1999, 25(Supplement):S30-38.

Just as the data show that women have abortions despite restrictive laws, they also indicate that women do not have abortions because of liberal ones. Some of the world's lowest abortion rates are in western European countries, where abortion is not only legal but also covered as a standard service by national health insurance systems: For example, the abortion rate in Germany is less than one-quarter that in Columbia, and the rate in the Netherlands is some six times lower than the rate in the Dominican Republic.

The Case for Contraception

The trend toward women wanting and having smaller families, and trying to time their children's births, is nearly universal. For decades, women in the United States, like those in many European countries, typically have wanted no more than two children, whereas in Latin America, Asia, the Middle East and North Africa, women now generally want 2-3 children. Large families are still desired in Sub-Saharan Africa, 5-6 children on average, but even there, women want smaller families than their mothers and grandmothers did.

In societies in which the desire for smaller families is strong, women will use every available resource and method to control their fertility. In the case of Russia and many other eastern European countries—where small families have long been the norm but modern contraceptives have mostly not been available—abortion rates historically have been among the world's highest. (Until quite recently, the contraceptive options available to Russians were largely low-quality condoms and one-size-fits-all diaphragms.) Russia legalized abortion in 1955 in response to the public health problem of illegal procedures. At that time, it was not uncommon for a woman wanting only two children to have 10 or more abortions in her lifetime, and as late as 1990, Russia's abortion rate was well over 100 per 1,000 women of reproductive age.

The situation began to change in the late 1980s, when free market reforms opened the door to modern contraceptives made in western Europe. Then in 1992, the Russian government, which had always subsidized abortion services, began subsidizing family planning programs and promoting contraceptive use by distributing free contraceptives. The results have been dramatic: In the ensuing decade, contraceptive use rose and the abortion rate plummeted (see chart).

Dramatic Results
Between 1988 and 2001, modern contraceptive use increased in Russia by 74%, while the abortion rate declined by 61%.

Source: Westoff C, unpublished data, 2003.

Recent policy changes threaten this emerging success story, however. Antiabortion and anti-family planning sentiment has been growing among the country's policymakers amidst pressure from the Russian Orthodox Church and deepening social anxiety over an impending "birth dearth." (Some experts predict that rising death rates and low birthrates could shrink Russia's population by about one-third over the next 50 years.) The government ceased its support for contraceptive programs in 1997, and the abortion restrictions implemented this August sharply limit women's access to abortions after the first trimester by eliminating two-thirds of the "social" conditions previously justifying second-trimester procedures.

Although the impact of these policy changes remains to be seen, making later abortions harder to obtain is not likely to affect the country's birthrate. (Russian women say more favorable economic conditions will help that situation, according to a recent story in the Los Angeles Times.) Nor will it have much impact on the abortion rate, as more than 90% of all abortions in Russia take place in the first trimester. On the other hand, a leading antiabortion parliamentarian was quoted in the Times as declaring that the second-trimester restrictions are "only the first step."

Meanwhile, despite being cut off by the central government, many Russian family planning clinics continue to subsist on local funding. Tellingly, according to a recent report on CNN's Web site, while abortion rates continue to decline throughout Russia, they are dropping more rapidly where clinics remain. For example, in the region of Dubna, where clinics are still active, the abortion rate is only about half the national average. Vladimir Serov, deputy director of Moscow's Scientific Center for Obstetrics, Gynecology and Perinatology, believes that the government's lack of support for contraceptive services deserves much of the blame for why abortion is still so prevalent in Russia. "Restrictions [on abortion] are useless," asserts Serov. "We need to promote a healthy way of life and family planning."

Time, Method Mix and Quality of Care

In many countries, the shift from relying on abortion to more widespread contraceptive practice is neither as abrupt nor as dramatic as it was in Russia. Although the end result is almost always the same, the patterns can vary depending on many factors, including whether overall desired family size is still dropping or has already stabilized, how much women had been using abortion to control their fertility prior to the introduction of contraception, and the availability and accessibility of modern versus traditional methods.

South Korea, for example, experienced a dramatic decrease in desired family size beginning in the 1960s, and the average number of children per woman fell by more than half over a 20-year period. During most of this period, abortion and contraceptive prevalence rates rose simultaneously as women's motivation for small families intensified. Eventually, as the country's total fertility rate began to stabilize, the abortion rate stabilized and then began to fall, while contraceptive use continued to increase (see chart).

It Takes Time
Initially, rapid fertility decline in South Korea was accompanied by increases in both contraceptive use and abortion; over time, abortion rates turned downward while contraceptive use continued to climb.
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Note: Abortion rates are expressed per 1,000 women of reproductive age, contraceptive prevalence per 100 married women of reproductive age and TFRs per 10 women. Source: Marston C and Cleland J, Relationships between contraception and abortion: a review of the evidence, International Family Planning Perspectives, 2003, 29(1):6-13.

Abortion rates in South Korea took so long to start their decline in large part because of women's continued reliance on less effective, traditional contraceptive methods. Above and beyond an overall increase in contraceptive use, a shift from traditional methods, such as withdrawal, to more effective, modern methods can have a significant impact on a country's abortion rate.

This can be seen in Turkey, where abortion rates dropped from 45 to 24 per 1,000 married women between 1988 and 1998, while overall contraceptive use rates remained essentially the same. According to an analysis by Pinar Senlet and colleagues published in the March 2001 issue of Studies in Family Planning, use of modern contraceptives in Turkey increased during that time, while use of traditional methods decreased. Between 1993 and 1998, the shift to modern method use was most pronounced among women in their peak reproductive years (25-39), the same age-group which had the most pronounced decline in abortion rate.

Senlet and colleagues conclude, "Marked reductions in the number of abortions have been achieved in Turkey through improved contraceptive use rather than increased use." Given that withdrawal is still the method of contraception most commonly practiced by Turkish women and that almost half of all abortions in Turkey are preceded by the failure or discontinuation of a traditional method, the authors suggest that "shifts in the method mix toward more effective methods and more effective use of methods have considerable potential to reduce abortion levels, even in the absence of increased use."

Meanwhile, a long-term study of the impact of family planning service delivery in the rural Matlab district of Bangladesh demonstrates the important role that quality of care can play in suppressing a country's abortion rate even in a period of rapid transition to smaller family size. Since 1977, the Maternal and Child Health and Family Planning Project (MCH-FP) has been providing family planning services in Matlab, and compared with the standard services provided by government Health and Family Welfare Centres, MCH-FP services are characterized by a broader mix of contraceptive methods, more home visits by family planning workers and more time spent counseling individual women. In 1979, the abortion rate in the MCH-FP area was the same as the rate in the comparison area, but by 1998, the abortion rate in the comparison area was three times higher than the MCH-FP area's rate. This is a direct result of the fact that unintended pregnancy, which declined in both areas, dropped much more where MCH-FP services were available (see chart, page 10).

Quality Counts
In Bangladesh, access to contraceptives reduced un-intended pregnancy both in areas served by MCH-FP clinics and in comparison areas, but rates dropped more sharply where the higher-quality MCH-FP services were available.
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Note: MCH-FP=maternal child health and family planning. Source: Rahman M, Davanzo J and Razzaque A, Do family planning services reduce abortion in Bangladesh? The Lancet, 2001, 358(9287):1051-1056.

The authors of the analysis note that during this 20-year period, fertility in Bangladesh dropped dramatically, from about 6.5 to 3.3 births per woman. In addition, they observe that "the remarkable fertility declines that have occurred throughout Bangladesh have been achieved with much less abortion than in other countries with similar fertility declines." In large part, they credit "the political priority that the Bangladesh government has placed on fertility reduction and family planning services," stating that even in the comparison area, "it is very likely that abortion...would have been higher were it not for the family planning services the government provided."

Implications for the United States

In the United States, small families have been the norm since at least the 1920s, modern contraceptives are widely used and abortion rates—though higher than many countries in western Europe—have declined over the last two decades and fall in the lower-to-moderate range by worldwide standards. Clearly, progress has been made in reducing unintended pregnancy and abortion rates, but there is a distance to go.

Social conservatives argue that more emphasis should be placed on restricting or outlawing abortion and on promoting abstinence for young and unmarried people. Although encouraging and enabling young people to delay the initiation of sexual activity certainly has a role to play in further reducing U.S. unintended pregnancy and abortion rates, abstinence as a method of pregnancy prevention will not work for all young people. Furthermore, it will rarely suffice for almost any individual woman over the course of the 30 or so years of her life during which she could be at risk of unintended pregnancy. As for making abortion illegal, our own history as well as experience from around the world amply demonstrate that if legal restrictions work at all, they do so largely by driving abortion underground—which does not end abortion, but makes it more dangerous for women.

In contrast, the evidence clearly shows that contraceptive use works. On a personal level, it reduces the probability of having an abortion by an estimated 85%. And at the program level, publicly subsidized family planning services in the United States have been shown to have helped women prevent 20 million pregnancies over the last 20 years, nine million of which would have been expected to end in abortion. Indeed, in the United States today, the small fraction of women—some 7%—who are sexually active and at risk of unintended pregnancy but do not practice contraception are responsible for almost half of the unintended pregnancies and nearly half of the abortions.

The overwhelming majority of sexually active women in this country seek to prevent unintended pregnancy by practicing contraception; however, women, their partners and technology are not perfect. Therefore, one of the key challenges in further reducing the abortion rate in the United States (and in many other countries around the world) is to increase contraceptive access across the entire society and to facilitate more consistent and more effective contraceptive use.