Abortion round the worldBMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39393.491968.94 (Published 15 November 2007) Cite this as: BMJ 2007;335:1018
Abortion is one of the most emotive and divisive of medical issues. The review of the 1967 Abortion Act by the House of Commons select committee on science and technology aimed to avoid complex ethical questions by sticking solely to scientific and medical developments. Nevertheless, the committee's cross party membership was irreconcilably divided when the final report was published last month. Two conservative MPs decided they could not with good conscience agree with the final conclusions—that women should not need the consent of two doctors for the procedure—claiming that they had been misled over survival rates and the extent to which fetuses can feel pain.
Highly charged public discussions on abortion in the United States have also been given new impetus over the past few years, with speculation about the likelihood of a conservative dominated Supreme Court overturning the landmark 1973 legal ruling for Roe versus Wade. This decreed that women's right to terminate early pregnancies was enshrined in the 14th amendment.
New estimates for the numbers of abortions,1 both legal and clandestine, worldwide, which were released last month as part of the Women Deliver conference in London, show that although the numbers of abortions have fallen considerably in developed countries, numbers in developing countries are going up.2 Because poor countries harbour some of the strictest laws banning the procedure, more abortions mean more complications from botched operations and more deaths⇓.
Where governments accept abortion, even if they do not condone it, termination is less likely to produce severe health consequences. However, improving access to services is considerably more complex that just changing the law, as a new study of doctors' attitudes in Brazil shows.3 Although most doctors agree that women should be able to have an abortion if they need one, far fewer medical professionals are prepared to perform the procedure—and this attitude is a barrier to access to abortion services even in countries where they are available.
Trends in abortions
Of the 210 million conceptions annually worldwide, almost half do not result in a live birth.2 Eighty million pregnancies end early, 42 million of these are terminated through abortions (20 million done illegally), and another 3 million babies are stillborn. Most of the abortions are carried out in the developing world
The previous analysis of worldwide numbers of abortions in 1995 recorded 46 million procedures. The drop to 42 million by 2003, the latest year for which figures are available, has occurred mainly in developed countries, where abortion is legal, albeit contingent on various conditions being met. “We calculate that one in five pregnancies ends in abortion worldwide,” says Sharon Camp, president of the US based Guttmacher Institute, a sexual and reproductive health think tank that collaborated with the World Health Organization to compile the data. “Sixteen per cent of pregnancies end in unwanted or mistimed birth, and overall over one third of pregnancies are unintended,” she adds.
In what seems to be a plateauing of a long term decline, the smallest drop since 1995 was observed in the US, which still has the highest abortion rate of any Western country, with half of pregnancies being unintended. The biggest drop occurred in Europe, which traditionally had high rates. “If we deconstruct the European drop, then it is clear that this is due to a steep decline in eastern Europe,” explains Dr Camp. “There was in fact a small rise in western Europe due to immigration of people with low levels of contraceptive awareness. One general truth is that abortion rates decline as contraceptive use increases,” she says.
Dr Camp notes that the reason most abortions now occur in less developed countries is simply that this is where most of the world's women live, with China alone accounting for 9 million abortions a year. “The new data make it clear that prevention works; prohibition does not,” says Dr Camp. “Abortion is lowest where contraception and safe, legal, abortions are universally available. What is more, major abortion declines have occurred in countries where abortion is legal but not in countries where abortion is restricted.”
However, another study suggests that simply making abortion legal does not guarantee the drop in procedures seen in Europe. Paul Van Look, of WHO's department of reproductive health and research, believes that legality and safety are not always synonymous. Although most legal procedures are safe, “there are certain circumstances in which procedures condoned by law are classed by WHO as unsafe abortion”—for instance, where the procedure is done by a non-medically qualified person or when the care does not conform to legal standards. “The case fatality rate [for illegal abortions] is 70 times higher than for legal abortions,” he says.
Half of these potentially dangerous procedures are done in Asia and 28% in Africa; most are illegal, but not necessarily so because of the poor access to reproductive health services. Most are done in women aged 15-24 and are associated with a large burden of long term reproductive morbidity. Each year 66 500 deaths are attributable to unsafe abortion and, although Asia has far more unsafe procedures, 54% of all deaths occur in Africa.
In Latin America the death rate is much lower, although the number of illegal abortions is high. This is partly because the more developed health system is better able to cope with complications of badly done procedures, says Dr Van Look.
Can legalisation alter this health burden? In Latin America, the abortion rate has dropped in the past decade, but most abortions remain unsafe. Restrictive abortion laws in many countries are partly to blame—the procedure is banned in Chile, El Salvador, Honduras, the Dominican Republic, and the Dutch Antilles—but women are still unable to get abortions even when it is legal. Health providers and the public do not know the legal situation, according to Anibal Faundes, professor of obstetrics and gynaecology at the University of Campinas in Brazil.
Professor Faundes asserts that health administrators give little consideration to the human right of access to safe abortion for women who comply with the law. “Women do not have the same rights as men in our countries,” he says. “What is more, even when the law is known by health providers, there are no regulations about how to put it into practice. Physicians do not feel safe to do it because they don't know the rules about how to do it. Physicians also may think that every case needs a judge's decision, which can take longer than a pregnancy.”
He believes that doctors have a role in making abortion accessible to women through complying with the law, but also by campaigning for a change in the law. The problem is that doctors are not always willing participants in this debate. In Professor Faundes and colleagues' study of the attitudes of Brazilian doctors to abortion, only 38.5% of doctors said that women should have access to abortion if a woman requests it and 85% believed it was appropriate in cases of rape or incest.3 The picture is complex: “Physicians generally agree with women's right to abortion but they don't believe their colleagues do, which affects their professional decision making. Therefore, it is important to show them that they are not alone.”
Of the 85% of doctors who supported abortion after rape, only 35% would do the procedure themselves. Half would leave colleagues to do it, and the remainder would advise a woman to seek another doctor, refer elsewhere, or turn the woman away with no advice. Professor Faundes believes the key to improving women's access to services is helping doctors to overcome their resistance to performing legal abortions. One option is making them more familiar with the situations of women who request the procedure. “The closer physicians are to women with an unwanted pregnancy, the more likely they are to consider abortion morally acceptable,” he says. Almost 80% of physicians said they would help a partner, but only 40% would help a client. “Physicians are not the only barrier, but they can be moved from being part of the problem to part of the solution,” he says.
Dr Van Look agrees. “Whatever the law, people should have access to the full extent of it. Providers should not turn away women when they are entitled to an abortion,” he says.
Competing interests: None declared.