When the US Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization overturned the constitutional right to an abortion on June 24, 2022, the United States became an outlier on the global stage. Some 52 countries changed their abortion laws between January 2000 and May 2022,* and all but two of these countries expanded the grounds for legal abortion.¹ Countries that expanded the grounds for legal abortion often did so to reduce maternal death and illness, ensure access to basic health care (which includes abortion services), and recognize the right of individuals to make their own decisions about pregnancy and childbearing. Nicaragua, Poland and now the United States are the only nations to have backtracked on legal grounds for abortion in this century.

The United States is an anomaly when compared with other high-income countries, where abortion is almost universally legal on broad grounds. Before the Supreme Court ruling, as of 2019, only 0.5% of women of reproductive age^† in Europe and North America lived under restrictive abortion laws. Even in Ireland, where the population is overwhelmingly Catholic, abortion was made legal on request in 2019. Yet, because abortion laws are restrictive in most low- and middle-income countries, four in 10 women of reproductive age worldwide live in countries with restrictive abortion laws.²

With abortion in the United States now legislated at the state level, the country as a whole cannot be categorized as having either a protective or restrictive abortion law. Rather, the Dobbs decision has resulted in a chaotic legal patchwork that, as of August 2022, leaves some 22 million US women of reproductive age living under highly restrictive laws more typical of low- and middle-income countries than of high-income countries. More states are likely to adopt restrictive policies as court cases are resolved and state legislatures reconvene in 2023.

Restrictive Laws Lead to Unsafe Abortions

Historically, legal restrictions on abortion have proven ineffective at curtailing the incidence of abortion. Global, regional and national estimates of abortion incidence have repeatedly shown that abortion is no less common in settings with restrictive laws than in those where it is broadly legal.³ But where abortions are largely illegal, they are more likely to occur under unsafe conditions.⁴

The World Health Organization (WHO) defines safe abortions as those carried out using a recommended method appropriate to the gestational age, and by someone with the necessary skills.⁵ In countries where abortion is legal without restriction as to reason, almost nine out of 10 abortions happen safely, and in many nearly all abortions are done under safe conditions. But where abortions are highly restricted legally, only 25% of abortions happen safely.

The Consequences of Restrictive Abortion Laws Are Highly Inequitable

Before abortion was widely legal throughout Europe, some women crossed national borders to obtain safe and legal abortions. For example, before abortion was fully legalized in Ireland in 2019, thousands of Irish women traveled to England each year to terminate their pregnancies.⁶ Some US women living in restrictive states may have the option of crossing state (or even national) borders for care—if they have time, money, information and other resources needed to make it happen.

In addition, in the past 20 years or so, medication abortion—the use of mifepristone and misoprostol, or use of misoprostol alone—has spread across the globe. Even in countries where abortion is largely illegal, many women who need to end a pregnancy manage to obtain these drugs through informal channels. Evidence indicates that access to medication abortion has helped to reduce maternal illness and death in many settings with restrictive abortion laws.⁷

Even with these backdoor paths to safe abortion in restrictive settings, however, unsafe abortion is common in legally restrictive settings. According to the most recent estimates, 35 million women have abortions under unsafe conditions in low- and middle-income countries, and 20 million of those women end up needing (but not always receiving) medical care for complications from unsafe abortion.⁸ Evidence from several countries shows that women living in poverty and in rural regions are more likely than their better-off and more urban counterparts to develop complications from unsafe abortion—but are less likely to receive treatment.⁷

Evidence from countries around the globe suggests that, although restrictive abortion laws in many US states are unlikely to substantially lower the incidence of abortion, they will likely increase the proportion of abortions done under unsafe conditions.

Unsafe abortion in the United States might not become as prevalent—and associated health risks may not be as severe—following Dobbs as was the situation preceding Roe. This is because some people seeking to end a pregnancy will be able to obtain safe medication abortion for home use or will travel to obtain a legal abortion. Nonetheless, the abortion restrictions resulting from the Dobbs decision will negatively impact the health of many people who wish to terminate their pregnancies, and negative health consequences are likely to be concentrated among women who lack both access to information and the resources needed to overcome barriers to obtaining a safe procedure. Already, women with low incomes make up the majority of US abortion patients. Black women also have a higher rate of abortion than their White counterparts.⁹

Reverberations of the Court’s Decision Could Be Global

There is reason to be concerned that the impacts of the Dobbs decision will reach far beyond the United States. Many international organizations and policymakers are concerned that this rollback of legal protections for abortion could strengthen efforts in other countries to slow, prevent or even reverse abortion law reform and could endanger access to abortion services.¹⁰ As a colleague engaged in such reform in West Africa recently said, "We are very worried what will happen to the fledgling movement on the continent to relax abortion laws."

An important new resource—which stands in sharp contrast to the position expressed in the Dobbs decision and ensuing US restrictions—is available to guide national and regional approaches to abortion legality and provision. WHO’s evidence-based guidelines on comprehensive safe abortion services, updated earlier this year, recommend removing medically unnecessary policy barriers to safe abortion, such as criminalization, mandatory waiting times, and the requirement that consent must be given by partners or family members.⁵ In addition, for the first time, these WHO guidelines endorse the use of telemedicine for medication abortion under appropriate conditions.

The US Supreme Court’s decision runs counter to the overwhelming international trend toward expanding abortion rights. If other countries continue on that trajectory by enacting evidence-based policies and supporting sexual and reproductive rights, they can avert the harms that will likely befall some US women—especially those with few resources—in the months and years to come.