Legal abortion rates vary widely among countries with nonrestrictive laws.1 In 1995-1996, rates ranged from a low of seven abortions per 1,000 women aged 15-44 in Belgium and the Netherlands to a high of at least 83 per 1,000 in Vietnam. Some developed countries have rates close to that in Vietnam, a developing country; for example, the rate is at least 78 per 1,000 in Romania and 68 per 1,000 in the Russian Federation.2
Perhaps the most important factors affecting the abortion rate are the strength of motivation to have a small family and control the timing of births, and the extent of effective use of contraceptives. Although it is the policy of most countries to encourage contraceptive use, not all have provided support or allocated the necessary resources to family planning services. As a result, lack of access to contraceptive services and supplies can be an important barrier to the use of family planning. Negative attitudes toward various contraceptive methods may also impede change. In addition, it may be difficult in some countries for health systems accustomed to providing abortion services to shift to an emphasis on contraception. Finally, some countries with high abortion rates are said to have an "abortion culture," implying that reliance on abortion will be slow to change, regardless of contraceptive availability.
If a country's birthrate remains stable, a declining trend in the abortion rate suggests success in substituting contraception for abortion. Information on trends is important for understanding policies concerning abortion and contraception and perhaps the factors that impede the success of these policies. Recent experience also sheds light on the speed with which abortion rates can change and the level of abortion that a country can reasonably hope to achieve.
This article reports trends in legal induced abortion in 54 countries* for the period 1975 to 1996. Although the majority of countries with data on the incidence of legal abortion are economically developed, enough information is available on developing countries to provide important insights. We have included data for countries in which abortion reporting is known to be incomplete, because the time trends are often meaningful even if the absolute level of abortion is uncertain.
Methods and Data Sources
Abortion data are generally collected by government agencies that compile statistics from health facilities and physicians who perform abortions. Our aim was to obtain abortion statistics from all countries that had a population of one million or more and where abortion was legal in 1997 under broad conditions or where the law was more restrictive but legal abortion services were widely available. In each country for which we believed data would be available, we contacted the national statistical office or a local informed expert with our request for information and for published reports containing abortion statistics.§
We present abortion rates based on government abortion statistics for 48 countries and taken from other sources for six countries where governmental sources do not exist or where other sources are more complete. For one of the six, Switzerland, the number of abortions was taken from a publication reporting the number in each canton (with estimates for two cantons).3 For the United States, we used data collected through periodic surveys of all abortion providers by The Alan Guttmacher Institute (AGI)4 instead of government statistics (which are incomplete for many states). For France and Italy, we used estimates made by local experts that attempt to correct for underreporting in the official statistics.5
For South Korea and Turkey, we present estimates from surveys of ever-married women aged 20-44 (Korea) or 15-49 (Turkey) that asked women about their abortion experience in the previous year.6 The number of abortions for each of these countries is underestimated because abortions to unmarried women are not included.
For population estimates needed to calculate rates, where possible we used data from official sources that were either published, provided by country statistical offices or provided by our in-country experts. For countries for which we could not obtain official estimates of the population of women aged 15-44, we relied on the estimates of the United Nations Population Division, with interpolation where necessary.7
Although reporting is usually required, it is nevertheless incomplete—and thus potentially misleading—in many countries. Therefore, we asked local experts to assess the completeness of the data, and we have set apart results for countries where reporting is incomplete or of unknown completeness. Despite the incompleteness of data in some countries, we have assumed—in the absence of information to the contrary—that the data on trends are generally reliable. Instances in which the completeness of reporting is likely to have changed over time are noted in the text.
The most striking recent trends in abortion incidence have occurred in the formerly socialist countries of Eastern and Central Europe and the former Soviet Union, where abortion rates have fallen sharply (Table 1). Although abortions performed in newly established private services in many of these countries may be underreported, rates dropped substantially between 1991 and 1996 in all four of the former Soviet republics where reporting is believed to be reasonably complete—by 28% in Belarus, 32% in Estonia, 47% in Kazakhstan and 32% in Latvia.
In six Soviet successor states where reporting is incomplete or of unknown completeness, the rate fell by between 18% (Azerbaijan) and 65% (Kyrgyzstan). The rate in the Russian Federation dropped by 27% between 1991 and 1995. Only one former Soviet republic (Armenia) experienced a rate increase, from 32 per 1,000 in 1991 to 35 per 1,000 in 1996. Because reporting after independence may have become less complete in these six countries, the actual declines may be somewhat smaller than those shown.
Between 1980 and 1990, abortion rates in the former Soviet states were generally declining or stable. In several of these countries, however, the rate appeared to increase in 1988 and 1990 when "miniabortions" (early vacuum aspiration abortions permitted outside of hospitals under new regulations) first began to be included in the reports. In three of the four countries thought to have complete data, the decline began well before the shift from Communism—in 1988 in Estonia, 1980 in Kazakhstan and 1986 in Latvia. In Belarus, the decline began only in 1991, after independence.
The pattern was generally similar in the other formerly socialist countries of Europe. In Bulgaria and Hungary, rates were relatively stable until around 1991 but have since decreased by 24% and 15%, respectively, even though both countries have liberalized their abortion laws since 1988 and have experienced falling fertility rates. The abortion rates of the Czech and Slovak Republics have dropped by about half since 1991, after having increased during the 1980s. Albania saw a sharp increase in its rate of legal abortion after restrictions on first-trimester procedures were lifted in 1991, as reported legal abortions replaced illegal ones; since 1993, however, the reported rate has fallen and now approximates that of other nearby Balkan countries.
In Poland, the legal abortion rate is currently near zero as a consequence of new restrictions (data not shown). Nevertheless, many Poles reportedly seek abortion services in nearby countries or from illegal providers in Poland.8 The reported abortion rate in Romania has fallen sharply from its high 1991 level (159 per 1,000), but a population survey found an increase in abortions between 1991 and 1992,9 indicating that the apparent decline at least partly reflected private-sector abortions that were not reported.
Before its breakup, the former Yugoslavia had a relatively high abortion rate (71 per 1,000 in 1984, not shown). Since 1991, rates have fallen in all of its successor republics. In Slovenia, where reporting is believed to be relatively complete, the rate has fallen by 25% to 23 abortions per 1,000 women, a rate comparable to the highest levels among developed countries without a Communist history. The reported rates in Croatia, Macedonia and Yugoslavia (Serbia and Montenegro) appear to have fallen even more, but these statistics may be incomplete.
Abortion rates in many other developed countries have also declined. Denmark, Finland, Italy and Japan have experienced sustained drops since 1975 of 40%, 51%, 39% (since 1980) and 47%, respectively. Smaller declines have occurred since 1980 in France, Germany,** Israel and the United States. Although reporting is incomplete in some of these countries, local experts consider the level of consistency stable enough over time to reliably indicate the trend.
Rates since 1980 have been relatively stable in England and Wales, the Netherlands, Norway, Sweden and Switzerland. In Belgium, the rate was no higher in 1993-1996, when abortion was legally permitted, than in 1988, when abortion was illegal but nevertheless provided openly in clinics.
Several countries, including England and Wales, Finland, the Netherlands, Norway and Scotland, saw a change in trend in 1996, when their rates rose after having fallen in the previous year. Studies in two of the countries have suggested that the increase resulted from publicity about possible risks of third-generation oral contraceptives, which may have caused women to discontinue or avoid pill use.10
A few developed countries have experienced a pattern of rising abortion rates in recent years. In 1988, Canada's Supreme Court declared unconstitutional a law requiring that abortions be performed in hospitals and that they be approved by a hospital committee. Since that ruling, the establishment of clinics and the elimination of committee approval requirements have made services more accessible. In Ireland, where local observers believe that virtually no legal or illegal abortions are performed, an increasing number of women have been traveling to England for abortion services, indicating that the abortion rate is probably rising. Hong Kong, New Zealand and Scotland have also had long-term increases in abortion incidence, although their rates are still relatively low.
Among the developing countries with legal abortion statistics, patterns are varied. Rates in South Korea, Tunisia and Turkey are sharply declining; the reported abortion rate in China has also fallen. It is difficult to know, however, how much of the drop in China results from incomplete reporting of medical and private-sector abortions and how much reflects better contraceptive use and reliance on more effective methods (for example, the introduction of a better IUD).
In contrast, abortion incidence in Vietnam rose sixfold between 1984 and 1992. This trend is evident even without taking into account a large expansion in the provision of abortions in the private sector; thus, the true abortion rate in Vietnam may be one-third higher than the reported rate for recent years. In Cuba, the abortion rate rose in the late 1980s with the introduction of menstrual regulation.
Recent trends in legal abortion rates are predominantly downward, although they vary from country to country. The most striking change is that rates declined by one-fourth to one-half in the countries of the former Soviet Union and in Eastern and Central Europe during a period when fertility was also declining. The most likely immediate reason is greater use of modern contraceptives.11
It has been hypothesized that conditions in Romania led to cultural acceptance of abortion as a satisfactory or even preferred method of fertility control and that abortion rates would remain high even when the situation that led to reliance on abortion—insufficient availability of contraceptive services in a population with low fertility desires—had changed.12 The same reasoning would apply to the Soviet successor states, where an "abortion culture" was said to exist. The recent experience of Romania is inconclusive, because of uncertainty about the abortion rate, but the trend in the Soviet successor states casts doubt on this theory, given the rapid decline in abortion rates in those countries. Those states have demonstrated that under the right conditions, contraceptive use can increase rapidly and abortion can decline, even in a population with a long history of reliance on abortion for fertility control.
The key condition in the formerly socialist countries may be greater availability of contraceptive services and supplies, largely in the private sector and through efforts of nongovernmental organizations.13 In addition, in some countries, the imposition of fees for abortion services may have encouraged women to replace abortion with contraception. (According to an expert informant in the Czech Republic, recently introduced fees for abortion reflect the move to a market-driven economy rather than an attempt to discourage abortion.14) Even where fees have not been specifically imposed for abortion, patients are increasingly having to turn to private providers or to pay unofficially because public health care systems are underfunded.
Abortion rates are also declining in several other developed countries, including Denmark, Finland, France, Italy, Japan, the United States and probably Germany. Fertility has not risen in these countries, and it is unlikely that rates of sexual activity have fallen significantly or that the reporting of abortions has changed. Thus, the reductions in abortions are probably attributable to more effective contraceptive use.
While the reasons for increased effectiveness of contraceptive use are not completely clear, it is likely that over the long term, public understanding of contraception—the variety of methods, the correct use of those methods and knowledge of how to obtain appropriate services—has increased. In any case, the declining abortion rates in a large number of countries demonstrate that legal and free availability of abortion services does not generally cause populations to increase their reliance on abortion to control fertility.
The declines in England and Wales, France, and Sweden during the 1990s coincided with the introduction of early medical abortion using the antiprogesterone mifepristone (RU 486) in those countries. By 1995, mifepristone was employed in 16% of abortions in France,15 where it was first approved in September 1988. Thus, based on the experience so far in these three countries, it appears that introduction of this method does not cause an increase in the number of abortions.
Rates of abortion may be rising in some developing countries, however. It is common during periods of rapid fertility decline for populations to increase their use of both abortion and contraceptives to meet the desire for smaller families and to time births more exactly. Thus, for a substantial period of time, as fertility is declining, both the abortion rate and contraceptive prevalence may increase.16 A limited choice of contraceptive methods and erratic supplies in countries where couples want small families, as in Cuba and Vietnam, also help to explain the high level of abortion in some settings.
Eventually, however, contraceptive use drives down the abortion rate. South Korea illustrates this pattern: Between 1970 and 1996, the total fertility rate fell from 4.5 to 1.8 lifetime births per woman and contraceptive prevalence among married women aged 15-44 increased from 25% to 79%. Meanwhile, survey-based estimates of the abortion rate increased from 44 per 1,000 in 1970 to a peak of 64 per 1,000 in 1981, and then fell to 20 per 1,000 by 1996.17 Similarly, both fertility and abortion rates have declined in Tunisia and Turkey in recent years.
Legalization of abortion has the initial effect of increasing the number of reported abortions, as legal abortions replace illegal ones, and it probably also increases the total number of abortions as safe services become more widely available. Over the longer term, however, the extensive experience of the developed world and the more limited information from developing countries shows that abortion rates often decline. In some of these countries, the legislation that reduced restrictions on abortion was coupled with increased access to contraceptive services and, sometimes, increased governmental support for family planning. In addition, postabortion contraceptive counseling and services are more common in the context of legal abortion than in that of clandestine abortion. Thus, legalization may actually help to decrease the number of abortions if it stimulates efforts to improve family planning education and services.