Is abortion worldwide becoming more restrictive?BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8161 (Published 04 December 2012) Cite this as: BMJ 2012;345:e8161
Abortion has always been a subject for passionate public debate. But recently the temperature has risen, especially in the United States and Ireland. The Republic of Ireland has seen nationwide protests over the death of Savita Halappanavar, who was refused an abortion during a long and painful miscarriage because the fetus was still alive. After the fetus was finally removed she died of septicaemia and organ failure. The debate has also been reopened in the UK, where health minister Jeremy Hunt recently declared a desire to see the limit in England, Wales, and Scotland drop from 24 weeks to 12 and the prime minister expressed an interest in a more modest reduction.
In recent decades, abortion has become legal in all but five countries if a mother’s life is threatened. There has also been a general decline in the numbers of abortions worldwide as contraception has become more widely available. But World Health Organization figures show that the decline has slowed recently. So what’s going on? Is there a general shift towards tighter restrictions? Are people being discouraged from using family planning as populations dwindle? And is that forcing more women to take clandestine routes to terminate unwanted pregnancies?
Abortion is illegal under most circumstances in both the Republic of Ireland and Northern Ireland: it is allowed only when a mother’s life is in danger or her long term health seriously at risk. In Northern Ireland, the process for approving an abortion is very strict: two doctors must agree independently that the mother’s health is at risk and the abortion must take place within nine weeks of that decision. The NHS carries out between 30 and 50 abortions a year in Northern Ireland,1 and last year 1007 women travelled to other UK countries for abortions.2 In October, Marie Stopes opened the country’s first private abortion clinic in Belfast. The organisation says it plans to work within Northern Ireland’s legal framework, but anti-abortion groups say it aims to widen access to abortion on mental health grounds.3
In the Republic of Ireland the circumstances in which a woman’s life is deemed to be at risk are not entirely clear, and the recent case of Savita Halappanavar highlighted the fact that even when a woman’s life is threatened some doctors or institutions do not consider abortion an option. At least 4149 Irish women made the journey to the UK for abortions in 2011.2 Ireland is currently revising its guidelines on what constitutes a risk to a woman’s health after three women challenged the country’s constitution in the European Court of Human Rights.4 Anti-abortion groups argue that there are always ways to protect a woman’s health without carrying out an abortion and fear that the new regulations will be the first step towards widening access to abortion.
China’s single child policy means that there are an estimated 13 million abortions annually—making it the country with by far the highest number.5 The numbers are thought to have been rising since 2003, after a long period of decline, which has been attributed to increased premarital sex, disruptions in access to contraceptive services because of rapid urbanisation, and a lack of condom culture (six million abortions are in women under 25).6 However, the rapid changes in China have brought growing pressure for a change to the way the one child policy is enforced. Activists monitoring the policy say that instructions have been given to local authorities not to carry out late term forced abortions after one case involving a seven month pregnant woman caused national and international outcry this summer.7
Abortion is legal in India to protect the mother’s health, after rape, in insane women and underaged girls, or if the fetus has serious malformations. It is not legal as a way to avoid giving birth to a girl. There are hefty fines for those offering sex tests or abortions for sex selection. But India’s 2011 census showed a growing imbalance between the numbers of girls and boys aged 0-6 years, which research suggests is due to an increase in selective abortion of female fetuses.8 The government has so far failed to change or control the culture that prizes boys over girls and contributes to India having an estimated 11 million abortions per year. India’s ministry for Women and Child development reportedly wants to introduce fines and even prison terms for entire families who force a woman to abort a female fetus. And one state, Uttar Pradesh has introduced baby hatches where people can leave their unwanted baby girls.
Russia was the first country to legalise abortion in all circumstances and has the highest rate of abortion worldwide—54/1000 women aged 15-44 (compared with 24/1000 in China). Over the decades the policy has been changed, and recently it has been restricted by the government of Dmitri Medvedev, which has close ties with the Orthodox church and is facing a low birth rate and shrinking population. In October, parliament voted to limit the period for abortion to 12 weeks of gestation and up to 22 weeks in the case of rape.9 There is no time limit if there is a risk to the mother’s life. Abortion providers are now required to spend 10% of advertising costs on warning of the possible dangers to a woman’s health, and it is illegal to describe abortion as safe. The president’s wife has taken a leading role in anti-abortion campaigns alongside leaders of the Orthodox church.
Abortion has always been a subject of heated debate across the US, but in the past decade there has been a frenzied tightening of restrictions in many states that were previously moderate. Overall, according to the Guttmacher Institute, there were 92 new provisions restricting abortion in 2011, compared with 34 in 2005.10 This year there have been at least 39 new restrictions. In 2000, around a third of American women of reproductive age lived in states that were hostile to abortion rights, a third in states that were supportive, and a third in states that stood somewhere in between. By 2011, over half of American women lived in states that were hostile. States found different ways to obstruct women’s access to the procedure including insisting women must first receive counselling against it, restricting public or private insurance coverage, and making it difficult for physicians to obtain supplies of mifepristone, the FDA approved treatment for medical abortions. Seven largely rural states banned telemedicine for abortion in 2011, meaning a doctor has to be with the patient when prescribing the treatment.
In 2010, Nebraska came up with a new argument for restricting the period in which abortion is permitted. The state ruled to ban abortion after 20 weeks on the basis that the fetus can feel pain at that stage. This theory is not backed up by established science,11 but seven other states (Alabama, Idaho, Indiana, Kansas, Oklahoma, Georgia, and Louisiana) followed with similar rulings. Arizona restricted abortions beyond 18 weeks in March this year using a similar argument.
Critics argue that these laws are unconstitutional because the landmark 1973 Supreme Court ruling in the case of Roe versus Wade held that states could restrict or ban abortion only after fetal viability. It is generally agreed that a fetus could survive outside the womb from 24 weeks at the earliest. Critics also argue that if the concern is for the fetus not to experience pain it would suffice to use anaesthetics.
Latin America and Africa
In most of Latin America abortion is either totally banned (Nicaragua, El Salvador) or tightly restricted. Across Africa colonial laws make it legal in only a few situations—usually if a woman’s life is in danger or in the case of fetal abnormality or rape or incest. Social and religious disapproval also contributes to large numbers of women seeking clandestine abortion, which often leads to complications and deaths. WHO estimates that 5.5 million women in Africa have abortions every year, 99% of which are unsafe, and around 36 000 women die from the procedure.12 In Ethiopia, for example, unsafe abortions are thought to account for up to half of maternal deaths. Some 95% of abortions in Latin America are also unsafe.12
In both regions, a few countries have recently decided to relax their laws and make safe abortion services accessible on the basis that criminalising it causes unnecessary deaths. In Kenya, the constitution was changed in 2010 after years of debate over the need to relax the laws and increase provision of safe abortions. Argentina legalised abortion for raped women in March this year and Uruguay legalised abortion up to 12 weeks in October and is providing government funded abortion services. And since 2009, Ethiopia has piloted an apparently successful programme in which trained health workers in one region provide safe medical abortions with misoprostol.
Unlike most Muslim countries, Tunisia legalised abortion in the 1970s. The only conditions are that it must be carried out by a qualified practitioner within the first three months of pregnancy. The country’s leaders repressed the population in many ways before the Arab Spring of 2011 but they liberated women by encouraging all sorts of birth control in a bid to control population growth. As a result, the country has the lowest birth rate in the region—2.0 births/1000 women, according to the World Bank’s latest figures.13 It remains to be seen whether the Arab Spring will lead to a relaxing of laws across the Arab world, where abortion is generally available only if a woman’s life is in danger. Data are patchy but according to the International Planned Parenthood Federation, in the five years up to 2000, there were 15 million unwanted pregnancies across the Arab world and over seven million abortions in the same period.14 Clandestine abortions seem to be common, and it is estimated that 5% of maternal deaths are due to unsafe abortions. Because of cultural disapproval, most campaign groups are focusing on promoting better awareness and availability of contraception rather than safe abortions.
Iran has a relatively low abortion rate compared with other countries, probably because its well educated population makes better use of contraception. But the country’s leaders have begun slashing family planning services and appealing for bigger families in a bid to boost the population. It’s not yet clear how much families are heeding the call to procreate, but the changing government position is likely to produce an increase in the numbers of abortions.
Cite this as: BMJ 2012;345:e8161
Competing interests: All authors have completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.