Access to Safe Abortion in the Developing World: Saving Lives While Advancing Rights
At the London Summit on Family Planning earlier this year, donor and recipient country governments, pharmaceutical companies and civil society organizations from around the world made substantial new commitments toward the goal of significantly reducing the unmet need for contraception by 2020. These promises, if kept, will go a long way toward also reducing the number of abortions that take place each year in the developing world, but they cannot make the reality of abortion go away.
Levels of unintended pregnancy vary across societies and over time; however, because no reversible method of birth control is perfect and few human beings use methods perfectly, women will always experience unintended pregnancies. Thus, there will always be a need for abortion, and for safe abortion services. Tragically, of the roughly 44 million abortions that take place globally each year, a rising proportion—now about half—are medically unsafe.1 Virtually all unsafe abortions occur in developing countries, taking a devastating toll on women’s health and lives.
Reducing the incidence of unsafe abortion remains an urgent public health imperative. Beyond that, however, there is a growing recognition at the global level and within developing countries that access to comprehensive reproductive health services must include access to abortion—and that removing legal barriers to abortion not only protects women’s health, but restores their dignity and vindicates their basic human rights.
Global Abortion Rate Plateaus
According to a 2012 analysis by the Guttmacher Institute and the World Health Organization (WHO), what had been a downward trajectory in the worldwide abortion rate over the last couple of decades—which was accompanied by increasing contraceptive use rates—has now stalled.1 Moreover, abortion is becoming increasingly concentrated within the developing world; the vast majority of abortions take place in the world’s poorest countries. And it is in these countries where abortion is most often clandestine and unsafe (see chart).
The new study also reconfirms a longtime truth: that the frequency of abortion has much less to do with its legal status than with levels of unintended pregnancy. Unintended pregnancy levels, in turn, are influenced primarily by levels of modern contraceptive use.
Europe, which has both the lowest and highest abortion rates in the world, illustrates this truth. The lowest rates can be found in countries in Western Europe, where the average rate for the subregion is 12 per 1,000 women aged 15–44; the highest rates are in Eastern Europe, averaging 43 per 1,000. Abortion is broadly legal in both subregions. Levels of effective contraceptive use and unintended pregnancy, however, are radically different. In Western Europe, correct and consistent use of modern contraceptives is high and unintended pregnancy rates are low, whereas the opposite is true in Eastern Europe.
The average abortion rate across the countries of the former Soviet Union—90 per 1,000 women—was among the highest in the world in 1995.1 During the Cold War, modern contraceptives simply were not available in these countries; abortion was the method available to women for controlling births. The advent of modern contraceptives in these countries in the early 1990s began to drive the abortion rate down sharply to where it is now. The transition from primary reliance on abortion to contraceptive use as the means of controlling births is still a work in progress in Eastern Europe. Whether the momentum continues will depend on the supply of quality and effective methods, proper training of health care providers, the cost of services and adequate information for women about their choices. Already, however, the experience in Eastern Europe demonstrates unequivocally the effectiveness of contraceptive use in reducing unintended pregnancy and recourse to abortion.
In regions of the developing world where contraceptive use is relatively low, the average abortion 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.
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 remain unaware of the law and cannot surmount the many cultural, financial and geographic obstacles to obtaining services under sanitary conditions from medical professionals.2 Conversely, even where abortion is illegal, it is often true that at least more affluent women are able to obtain safe, if still underground, abortion services. Mainly, however, the evidence is consistent and compelling that where abortion is legal, it is much more likely to be safe, and where it is illegal, unsafe. Antiabortion advocates are often quick to point out the few exceptions to this general rule, but the fact remains that the countries in this category are outliers for some very specific reasons (see box).
South Africa, which legalized abortion in 1997, is a textbook example of the difference that legalization can make to the safety of abortion. It also proves that legalization alone is not enough. Additional steps must follow: medical training that can take place aboveboard, appropriate health and safety standards for clinical settings that can be established and enforced, information and referrals that can be made widely available to facilitate timely access to care, and costs that can be established not subject to extortion and that may be covered by public or private health insurance. Not nearly enough progress has occurred in South Africa to make safe abortion care there universal. Yet, even under imperfect conditions, abortion-related deaths in South Africa plummeted by as much as 90% in the years following legalization.7 Similarly, improved health outcomes for women are already becoming apparent in Ethiopia and Nepal, both of which legalized abortion only within the last decade.8
Where abortion is legal, safe and accessible, and as the many cultural barriers to care fall away, incomplete or septic abortion is far less likely, and so is the suffering and death that too often ensues. According to WHO, unsafe abortion remains one of the four leading causes of pregnancy-related death and injury around the world, along with hemorrhage, infection and high blood pressure in connection with childbirth. Although great improvements have been seen recently in the global maternal mortality rate, the proportion of deaths attributable to unsafe abortion is holding steady at 13%. This translates to 47,000 deaths each year, almost all occurring in countries with highly restrictive laws. Another eight million women suffer serious and sometimes permanent injury as a result of complications from medically unsafe abortion.9
The impact of unsafe abortion can be lessened to some extent by better access to treatment for the complications of unsafe abortion. However, this assumes the presence of adequate health systems and a woman’s ability to endure the stigma she is likely to face when she presents at a hospital with hemorrhage or infection resulting from an illegal abortion. In addition, particularly in Latin America, the severity of the complications from unsafe abortion is starting to decline significantly as more women rely on misoprostol.
Women and their families pay the main price of unsafe abortion, but countries pay as well, in terms of productive lives lost and dollars. A new analysis from Ethiopia presents the first comprehensive look at the true cost to the national health system of providing postabortion care.10 It found that the direct cost of treating postabortion complications in 2008 was $7.6 million, or $36 per woman treated. This, in a country where the average person lives on less than one dollar a day. Although Ethiopia legalized abortion in 2006, only one-quarter of all abortions in 2008 were performed under safe conditions. The study’s authors calculated that the costs of postabortion care could be slashed by ramping up investment in contraceptive services: Each additional dollar invested in family planning would save an estimated $6 in costs currently going toward the treatment of postabortion complications.
The Human Rights Lens
Clearly, the consequences of unsafe abortion can be reduced through better treatment and less unsafe methods. And the number of abortions can be decreased by preventing more unintended pregnancies through greater access to quality family planning services. For those abortions that will always be necessary, however, unsafe services must be replaced by safe services, for the sake of women’s health and lives. Further, governments have an obligation to remove criminal or other legal barriers to services, so that this key aspect of the global human right to health can be fully realized—as now recognized by a 2011 report by the United Nations (UN) Human Rights Council Special Rapporteur and more recently by WHO.11,12
The UN Human Rights Council appointed Anand Grover as its Special Rapporteur on the right to health in 2008. A prominent human rights lawyer in India with a long history working on issues relating to HIV and AIDS at the national and international levels, Grover has researched, analyzed and made recommendations to the council on a variety of health topics utilizing a human rights framework. In his 2011 report, Grover equates the offense of forced abortion with forced pregnancy and condemns governments for their complicity.11 He asserts that “the use of overt physical coercion by the State or non-State actors, such as in cases of forced sterilization, forced abortion, forced contraception and forced pregnancy has long been recognized as an unjustifiable form of State-sanctioned coercion and a violation of the right to health.” Likewise, he concludes, “where the criminal law is used as a tool by the State to regulate the conduct and decision-making of individuals in the context of the right to sexual and reproductive health the State coercively substitutes its will for that of the individual.”
Grover’s report is groundbreaking because it represents the first time an official report of the UN makes the case that laws criminalizing abortion or otherwise limiting its access or access to contraceptive services infringe women’s human rights. “Criminal laws and other legal restrictions on sexual and reproductive health may have a negative impact on the right to health in many ways, including by interfering with human dignity,” Grover writes. “Respect for dignity is fundamental to the realization of all human rights. Dignity requires that individuals are free to make personal decisions without interference from the State, especially in an area as important and intimate as sexual and reproductive health.”
Earlier this year, WHO picked up this theme and incorporated it into its new edition of Safe Abortion: Technical and Policy Guidance for Health Systems.12 This important report assesses and synthesizes the state of the research and evidence on abortion, and makes recommendations for clinicians, program managers and policymakers regarding abortion-related care. For the first time, WHO devotes considerable attention to articulating a rights-based framework for making abortion safe and truly accessible. Drawing on Grover’s analysis, the WHO report identifies the numerous international treaties and agreements that provide a legal basis for its conclusions. It summarizes the large body of research over the years demonstrating that making abortion illegal or difficult to obtain has a much greater impact on safety than on incidence. WHO notes that numerous UN treaty-monitoring bodies call for ensuring legal abortion at least in cases where the woman’s life or health would be endangered by continuing the pregnancy or in the event of rape or incest. (Notably, six in 10 of the more than 700 million women living in developing countries other than China and India live where abortion is completely banned or legal only to save a woman’s life.2) The report also highlights the importance not only of services delivered in a safe and timely manner, but in a way that ensures true informed consent, preserves a woman’s dignity and protects her confidentiality.
WHO places access to safe abortion services squarely within the right to quality sexual and reproductive health services, which WHO sees as fundamental to realizing women’s basic right to health. It speaks directly to policymakers in calling for the creation of an “enabling environment,” so that “every woman who is legally eligible has ready access to safe abortion care.” But WHO goes further than that to address law and policy directly. “Policies,” it asserts, “should be geared to respecting, protecting and fulfilling the human rights of women, to achieving positive health outcomes for women, to providing good-quality contraceptive information and services, and to meeting the particular needs of groups such as poor women, adolescents, rape survivors and women living with HIV. The respect, protection, and fulfillment of human rights require that comprehensive regulations and policies be in place…to ensure that abortion is safe and accessible.”
Abortion Legality, Safety and Maternal Mortality: The Outliers
Around the world, where abortion is highly restricted, it is not necessarily less common than elsewhere, but is almost always less safe—and this is reflected in country levels of pregnancy- related death and disability. Of course, there are a few countries that do not fit this mold, and they tend to share certain characteristics.
According to WHO, pregnancy-related death is very rare in Ireland and Malta, for example, yet abortion is entirely illegal in both countries. By no means does this mean that women in these countries never have abortions. Travel across borders is relatively easy in Europe, so women do not need to resort to clandestine, unsafe abortion, because they can and do go to nearby countries for safe abortion services or postabortion care. This phenomenon has been studied extensively in Ireland, where it is well-established that thousands of women travel to England each year to obtain safe abortion care.3
Some countries in Latin America also do not fit the pattern. Abortion is banned outright in Chile, for example, but the maternal mortality rate of 25 pregnancy-related deaths per 100,000 live births is relatively low compared with the rest of South America. In this case, it is noteworthy that since the 1960s, access to and use of modern contraceptives in Chile has improved greatly, leading to declines in unintended pregnancy, unsafe abortion and abortion-related hospitalizations.4 Moreover, an increasing proportion of the clandestine abortions that do occur result from women’s use of misoprostol—a safe, low-cost, legal and widely available over-the-counter drug (commonly used to prevent postpartum hemorrhage) that can be used to induce abortion without surgery. The use of misoprostol as an abortifacient has been widely promoted by women’s rights advocates in Chile since the 1990s, because it is associated with much lower risks of severe health consequences than illegal surgical procedures. Finally, Chile’s advanced health care system enables women who present themselves in hospital emergency rooms to receive effective treatment for postabortion complications, thereby greatly reducing the harms of unsafe abortion.
Two new studies looking at improvements in abortion complication rates in Brazil (where abortion is mostly illegal) and Colombia (which liberalized its law in 2006, but where access to safe services is still scarce) also conclude that increased reliance on misoprostol is a significant contributor.5,6 In all these countries, however, safer forms of clandestine abortion and better treatment of the complications of inadequate abortion care can only mitigate—not eliminate—the risks to women’s health where abortion is illegal and access to medically safe services is limited.
1. Sedgh G et al., Induced abortion: incidence and trends worldwide from 1995 to 2008, Lancet, 2012, 379(9816):625–632, <http://www.guttmacher.org/pubs/journals/Sedgh-Lancet-2012-01.pdf>, accessed Oct. 1, 2012.
2. Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009, <http://www. guttmacher.org/pubs/Abortion-Worldwide.pdf>, accessed Oct. 1, 2012.
3. Over 4,400 Irish women travelled to England and Wales for abortions in 2010, TheJournal.ie, May 25, 2011, <http://www.thejournal.ie/over-4400-irish-women-travelled-to-england-and-wales-for-abortions-in-2010-142753-May2011/>, accessed Oct. 1, 2012.
4. Guttmacher Institute, Review of a Study by Koch et al. on the Impact of Abortion Restrictions on Maternal Mortality in Chile, New York: Guttmacher Institute, 2012, <http://www.guttmacher.org/media/evidencecheck/2012/05/23/Guttmacher-Advisory.2012.05.23.pdf>, accessed Oct. 1, 2012.
5. Prada E, Singh S and Villarreal C, Health consequences of unsafe abortion in Colombia, 1989–2008, International Journal of Gynecology & Obstetrics, 2012, 118(Suppl. 2):S92–S98, <http://www.ijgo.org/article/S0020-7292%2812%2960006-X/abstract>, accessed Oct. 1, 2012.
6. Singh S, Monteiro MFG and Levin J, Trends in hospitalization for abortion-related complications in Brazil, 1992–2009: why the decline in numbers and severity? International Journal of Gynecology & Obstetrics, 2012, 118(Suppl. 2): S99–S106, <http://www.ijgo.org/article/S0020-7292%2812%2960007-1/abstract>, accessed Oct. 1, 2012.
7. Jewkes R et al., The impact of age on the epidemiology of incomplete abortions in South Africa after legislative change, BJOG, 2005, 112(3):355–359, <http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2004.00422.x/abstract;jsessionid=0C3D10A8DDC603DE4DBC425D533545A7.d03t01>, accessed Oct. 1, 2012.
8. Guttmacher Institute, Making Abortion Services Accessible in the Wake of Legal Reforms: A Framework and Six Case Studies, New York: Guttmacher Institute, 2012, <http://www.guttmacher.org/pubs/abortion-services-laws.pdf>, accessed Oct. 1, 2012.
9. Guttmacher Institute, Facts on induced abortion worldwide, In Brief, New York: Guttmacher Institute, 2012, <http://www.guttmacher.org/pubs/fb_IAW.html>, accessed Oct. 1,2012.
10. Vlassoff M et al., The health system cost of postabortion care in Ethiopia, International Journal of Gynecology & Obstetrics, 2012, 118(Suppl. 2): S127–S133, <http://www.ijgo.org/article/S0020-7292%2812%2960011-3/abstract>, accessed Oct. 1, 2012.
11. United Nations, Interim report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Aug. 3, 2011, <http://www.un.org/ga/search/view_doc.asp?symbol=A/66/254>, accessed Oct. 1, 2012.
12. World Health Organization (WHO), Safe Abortion: Technical and Policy Guidance for Health Systems, second ed., Geneva: WHO, 2012, <http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf>, accessed Oct. 1, 2012.