Abortion has been a reality in women’s lives since the beginning of recorded history, typically with a high risk of fatal consequences, until the last century when evolutions in the field of medicine, including techniques of safe abortion and effective methods of family planning, could have ended the need to seek unsafe abortion. The context of women’s lives globally is an important but often ignored variable, increasingly recognised in evolving human rights especially related to gender and reproduction. International and regional human rights instruments are being invoked where national laws result in violations of human rights such as health and life. The individual right to conscientious objection must be respected and better understood, and is not absolute. Health professional organisations have a role to play in clarifying responsibilities consistent with national laws and respecting reproductive rights. Seeking common ground using evidence rather than polarised opinion can assist the future focus.
Across the world, from the beginning of recorded history, women have been prepared to risk their lives when faced with an unwanted pregnancy. The reality of abortion is often minimised, yet even in current times globally about one in five pregnancies will end in an abortion, regardless of whether it is legal or safe. To consider abortion in isolation from the context of women’s lives and in the absence of evidence guarantees acrimony and is a well-documented cause of increased maternal mortality. The last century has been revolutionary in many ways, though for some women, their lives have changed little. The rights of women to vote, to hold public office and to be recognised as persons began in the late 19th century and continue to progress, but are still not universal. Advances in health and technology including antibiotics, blood transfusion, contraceptive methods and safe medical and surgical abortion techniques should have meant that women no longer need to put their lives at risk, although they may not have access to such services, nor the autonomy to make decisions on their own sexual and reproductive health. The recent United Nations (UN) resolution on the recognition of maternal mortality as a violation of human rights is a landmark decision in highlighting the need to urgently address unsafe abortion and prevention of unintended pregnancy. Human rights are generally considered to have emerged as an internationally agreed concept with the formation of the UN by Charter in 1945 resulting from international consensus on avoidance of the atrocities of the Second World War. Few consider these elements when discussing human rights and abortion, preferring to continue a narrow and polarised stance framed as support of or opposition to abortion, rather than seeking areas of common understanding that will bring us closer to reducing the numbers of abortions and preventing needless deaths and complications.
Background information: private decisions/public debate; how do people know what they know?
Women are recognised as central to the successful development of nations and it is no accident that the World Economic Forum in its annual Global Gender Gap (GGG) report is tracking indicators of gender-based human rights in four areas: economic participation and opportunity, educational attainment, political empowerment and health and survival. The GGG report includes indicators such as maternal mortality, fertility rates, contraceptive prevalence and adolescent pregnancy, in addition to the representation of women in parliament. The focus on women and health is also the topic of a World Health Organization (WHO) report in 2009 titled ‘Women and Health: today’s evidence tomorrow’s agenda’ that recognises that girls and women have greater needs of health systems due to their gender and reproductive roles and that these needs are not being met, thus impacting their health and that of their children. This recognition of the broader context of women’s lives for them to achieve optimal reproductive health is often lacking in discussions on abortion. It is important to remember that it was only at the end of the 19th and early 20th centuries that women began to gain the right to vote nationally and these rights continue to be granted even into the 21st century, most recently Bhutan, in 2008. The right to vote (suffrage) was explicitly mentioned for women in the Convention for the Elimination of Discrimination Against Women (CEDAW) in 1979. As an example of the evolution of women’s rights, in Canada, women were granted the right to vote in 1917 but were not recognised as persons until 1929, and Aboriginal women (and men) in Canada were not granted the right to vote at the federal level until 1960.
According to the 2009 GGG report, no country has yet reached gender equality, although the Nordic countries are the closest. Progress is being made in all indicators being measured though there are significant gaps between men and women in political decision-making at the highest levels and in economic outcomes, while gaps in education and health are generally closing more quickly in the 130 countries covered by the report. Overall, globally, women represented 18.6% of the parliamentary seats in 2009 and regional averages exceeded the UN target of 30% only in the Nordic region with 42.5%, with the Americas and Europe only reaching around 21–22%. It has been argued that equality of women includes, by necessity, a right to access safe abortion. This has not been viewed in isolation but in the context of availability of affordable public childcare, protection from domestic and sexual violence, equal employment opportunities, equal pay for comparable worth and inclusion of women in the public spheres of politics and governance.
Methods of abortion have been documented for thousands of years. Some may be surprised to learn that Hippocrates, whose oath is famous for its wording “…I will not give a woman a pessary to cause an abortion,” also reportedly described methods to terminate a pregnancy for medical indications in his Corpus Hippocraticum. In the 2008 debate on safe and legal access to abortion at the Parliamentary Assembly of the Council of Europe Ms Čurdová of the Czech Republic noted: “The 20th-century scientist, George Devereux, after examining 350 primitive, ancient societies, concluded that abortion was a universal phenomenon and that it was impossible to find or create a social structure in which it would not exist”.
Modern methods of contraception have only been in existence for the last 40–50 years and today a woman wishing to have two children would typically spend roughly 5 years pregnant, post-partum or trying to become pregnant, and almost three decades trying to avoid pregnancy. Even if she wished to have four children she would still spend at least 16 years trying to avoid pregnancy. In the period 1965–70 the proportion of married women practicing contraception was 9%. Although globally, it is encouraging that this figure reached 63% by 2003, according to the 2009 report from the Guttmacher Institute, an estimated 215 million women in the developing world still have an unmet need for modern contraceptives, meaning they want to avoid a pregnancy but are using a traditional family planning method or no method. Millions of women have no access to reproductive health services; many have little or no control in choosing whether to become pregnant. Various societal forces are at play that result in women and girls having sex or pregnancies they do not want, including gender-based violence. Faced with life-altering consequences of actions they may not be able to control, many women will seek to end the pregnancy, legally or illegally, by whatever means are accessible, available and affordable. These realities were brought sharply into focus in what could be considered social experimentation in Romania under the Ceauşescu pro-natalist regime.
In 1966, Romania, had access to safe abortion removed, concurrent with removal of access to contraception, both being made illegal. Those Romanian women who could afford it would fly to other countries to obtain abortions; those who could not resorted to ‘backstreet’ methods or gave their unwanted children to orphanages. This rapidly led to an increase in abortion-related mortality that was 10 times higher than other European countries. Ironically, there was a concurrent continuous fall in the crude birth rate after a brief rise. The pro-natalist policy failed in its goal but over the 22 years of the regime, over 10,000 women died from unsafe abortion and thousands of unwanted pregnancies resulted with children placed in institutions because their families could not care for them. Infant mortality also increased as data has shown that child mortality is significantly increased when the mother dies and since many of the women seeking abortion have children, their lives are also at risk, demonstrating that the simplistic goal of preventing an abortion does not mean a child will survive, let alone thrive.
Abortion facts and figures
Worldwide, the lifetime average is about one abortion per woman. In the United States, one in three women will have an abortion by the age of 45 years. Contrary to common belief, most women seeking abortion are married or living in stable unions and already have several children. A woman’s likelihood of having an abortion is similar regardless of whether she lives in a developed or developing region, but due to population distribution most abortions occur in developing countries. In 2003, there were 26 abortions per 1000 women aged 15–44 in developed countries compared with 29 per 1000 in developing countries. Worldwide, an estimated 5 million women are hospitalised each year for treatment of abortion-related complications, such as haemorrhage and sepsis. Legal restrictions on abortion do not affect its incidence, only its safety. For example, the abortion rate is 29 in Africa, where abortion is illegal under many circumstances in most countries, and is 28 in Europe, where abortion is generally permitted on broad grounds. Legal abortion has gone hand in hand with sharp increases in contraceptive use, which in turn has been a major factor in declining abortion rates. The decline in abortion incidence was greater in developed countries where nearly all abortions are safe and legal (from 39 to 26 abortions per 1000 women aged 15–44) than in developing countries, where more than half are unsafe and illegal (from 34 to 29). Despite what is sometimes portrayed, almost 90% of abortions in the US are within the first trimester, with about 60% in the first eight weeks. The proportion of abortions performed after the first trimester dropped rapidly after Roe vs. Wade. New medical and surgical technologies increasingly enable women to obtain abortions earlier in pregnancy.
Brazil, where abortion is very restricted, has one of the highest abortion rates in the developing world. The Health Ministry estimates that 31% of all pregnancies end in abortion, mostly clandestine. The lowest rates in the world are in Western and Northern Europe, where abortion is accessible with few restrictions. In the Netherlands, a country with some of the world’s most liberal abortion laws, the rate is closer to 10%. As noted by Ms. Gunn Karen Gjul in the debate on safe and legal access to abortion at the Parliamentary Assembly of the Council of Europe: “At the end of the 1970s all Nordic countries introduced liberal abortion legislation. With the exception of Iceland, the number of abortions decreased in all those countries after the introduction of that law. Belgium and the Netherlands have had the same experience. Obligatory sex education was introduced in schools and measures were taken to improve access to contraceptives.”
Abortion facts and figures
Worldwide, the lifetime average is about one abortion per woman. In the United States, one in three women will have an abortion by the age of 45 years. Contrary to common belief, most women seeking abortion are married or living in stable unions and already have several children. A woman’s likelihood of having an abortion is similar regardless of whether she lives in a developed or developing region, but due to population distribution most abortions occur in developing countries. In 2003, there were 26 abortions per 1000 women aged 15–44 in developed countries compared with 29 per 1000 in developing countries. Worldwide, an estimated 5 million women are hospitalised each year for treatment of abortion-related complications, such as haemorrhage and sepsis. Legal restrictions on abortion do not affect its incidence, only its safety. For example, the abortion rate is 29 in Africa, where abortion is illegal under many circumstances in most countries, and is 28 in Europe, where abortion is generally permitted on broad grounds. Legal abortion has gone hand in hand with sharp increases in contraceptive use, which in turn has been a major factor in declining abortion rates. The decline in abortion incidence was greater in developed countries where nearly all abortions are safe and legal (from 39 to 26 abortions per 1000 women aged 15–44) than in developing countries, where more than half are unsafe and illegal (from 34 to 29). Despite what is sometimes portrayed, almost 90% of abortions in the US are within the first trimester, with about 60% in the first eight weeks. The proportion of abortions performed after the first trimester dropped rapidly after Roe vs. Wade. New medical and surgical technologies increasingly enable women to obtain abortions earlier in pregnancy.
Brazil, where abortion is very restricted, has one of the highest abortion rates in the developing world. The Health Ministry estimates that 31% of all pregnancies end in abortion, mostly clandestine. The lowest rates in the world are in Western and Northern Europe, where abortion is accessible with few restrictions. In the Netherlands, a country with some of the world’s most liberal abortion laws, the rate is closer to 10%. As noted by Ms. Gunn Karen Gjul in the debate on safe and legal access to abortion at the Parliamentary Assembly of the Council of Europe: “At the end of the 1970s all Nordic countries introduced liberal abortion legislation. With the exception of Iceland, the number of abortions decreased in all those countries after the introduction of that law. Belgium and the Netherlands have had the same experience. Obligatory sex education was introduced in schools and measures were taken to improve access to contraceptives.”
Unsafe abortion
It is estimated that of the 210 million conceptions each year, about 1 in 10 result in an unsafe abortion, and an estimated 68 000 women die each year from unsafe abortion, with half of those deaths occurring in Africa. In Africa, one in four unsafe abortions occurs in teenagers. The vast majority of unsafe abortions, 98%, occur in developing countries, most with restrictive legislation. Unsafe abortion continues to be a recognised public health concern due to the higher incidence and severity of its associated complications, such as incomplete abortion, sepsis, haemorrhage and damage to internal organs. It consequently contributes to 13% of global maternal mortality.
Deaths from unsafe abortion are typically correlated with poverty and lack of implementation of women’s rights in general. Maternal mortality has additional impact on the estimated 220 000 children worldwide who lose their mothers annually due to abortion-related deaths. There is also growing evidence that, especially in adolescent girls, unintended pregnancy and unsafe abortion are associated with violence and sexual coercion. Rights to safe abortion are not equally available in the same country with the same law regulating access. A report by Lane in 1998 documented the relative ease by which wealthy women in Egypt can access safe abortion in such environments, whereas poor women are often faced with no option but to seek less safe alternatives.
The consequences of stigmatisation and judgement of women seeking or choosing abortion can be fatal in countries with restrictive legislation. In Fig. 1 , a review of delays in providing care in Gabon according to the cause of maternal death found that of the women who died, those women presenting with complications of abortion waited almost 24 h for appropriate medical attention compared with those presenting with post-partum haemorrhage or eclampsia. The authors concluded that the stigma associated with illegal abortion may result in health professionals not providing timely attention for women presenting with complications without realising the potential for fatal consequences.
Public and personal health costs of unsafe abortion
There may be later costs to the health-care system as well as personal tragedy for women who resort to unsafe abortion, and indeed women with spontaneous abortion who do not access health services. Both may suffer the consequences of Rh iso-immunisation in subsequent pregnancies if they do not receive Rh immune globulin – up to 2% of Rh-negative women who have a spontaneous abortion and 5% of those whose pregnancies are electively terminated. There are also significant adverse consequences on the health-care system that far exceed the cost of providing effective contraception and safe abortion as well as impacting the right to access of others by utilising scarce available resources. In Nigeria, an estimated cost of $19 m spent annually on treating complications of unsafe abortion could be avoided by spending $4.8 m on providing the contraceptive services necessary.
Human rights
This section will consider human rights relevant to discussion on abortion in the context of reproductive health overall as well as related rights that inform the context of women’s lives. Religion, ethics and societal moral values have influenced human rights law. The human rights involved in discussion of abortion include: the right to life and survival; the right to equal protection of the law; right of privacy, liberty and security; the right to the highest attainable standard of health; right to benefits of scientific progress; right to private and family life; and the right to non-discrimination on grounds of sex and gender.
International human rights
Defined as ‘basic rights and freedoms to which all humans are entitled’, the beginning of internationally recognised human rights was in The Charter of the UN signed on 26 June 1945 in San Francisco, with 51 founding members; four of the 160 signatories were women. There was strong support to create an international multi-government entity committed to achieving world peace after the atrocities of the Second World War. Article 1 on human rights relating to women states : “To develop friendly relations among nations based on respect for the principle of equal rights and self-determination of peoples, and to take other appropriate measures to strengthen universal peace” and “To achieve international co-operation in solving international problems of an economic, social, cultural, or humanitarian character, and in promoting and encouraging respect for human rights and for fundamental freedoms for all without distinction as to race, sex, language, or religion.”
In 1948, the General Assembly approved the Universal Declaration of Human Rights. Article 1 of the UN Universal Declaration of Human Rights states: “All human beings are born free and equal in dignity and rights”. The UN is a multi-lateral governmental agency with sole and universally accepted international jurisdiction for universal human rights legislation. In order to address the priorities of different ideologies in enacting the principles of the Universal Declaration in legally binding treaties, two separate covenants were created in 1966, the International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic, Social and Cultural Rights (ICESCR).
There are committees within the UN responsible for different human rights treaties and compliance of member states that have ratified them. States have the primary obligation to protect and promote human rights and report on measures they have taken to realise the rights enumerated in the ICCPR and other UN treaties. The most senior body of the UN with regard to human rights is the Office of the High Commissioner for Human Rights. The United Nations Human Rights Council, created at the 2005 World Summit to replace the UN Commission on Human Rights, has a mandate to investigate violations of human rights. Non-governmental organisations (NGOs) can submit communications to the Human Rights Committee that has ruled on the problems of unsafe abortion in countries.
Regional
There are three principal regional human rights instruments: the African Charter on Human and Peoples’ Rights, the American Convention on Human Rights (the Americas) and the European Convention on Human Rights. The Inter-American Commission on Human Rights (IACHR) is an autonomous body of the Organization of American States, based in Washington, DC and together with the Inter-American Court of Human Rights, based in San Jose, Costa Rica, is one of the bodies comprising the inter-American system for the promotion and protection of human rights. The European Court of Human Rights was originally unique in being the only international court with jurisdiction to address cases brought by individuals rather than states.
There is also the Arab Charter on Human Rights which does not include the right to health but includes the right to non-discrimination including on the basis of sex in Article 2 as well as the right to life, liberty and security of the person in Article 5.
There are no regional instruments in Asia or Oceania.
Right to the highest attainable standard of health
The United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health 2006 states “The right to health can be understood as the right to effective and integrated health system encompassing health care and the underlying determinants of health, which is responsive to national and local priorities, and accessible to all. Underpinned by the right to health, an effective health system is a core social institution no less than a court or political system”:
Table 1 indicates the international treaties recognising the right to health. The ICESCR recognises the right to health, requiring state parties to ensure the highest attainable standard of physical and mental health. The Committee on Economic, Social and Cultural Rights is the body responsible for monitoring the ICESCR where the right to health is articulated in detail. The right to health is also articulated in the CEDAW requiring states to take all appropriate measures to eliminate discrimination against women in the field of healthcare in order to ensure, on a basis of equality of men and women, access to health-care services, including those related to family planning.
| Year | International Treaty |
|---|---|
| 1948 | Universal Declaration of Human Rights: Article 25.1 |
| 1965 | International Convention on the Elimination of All Forms of Racial Discrimination: Article 5 (e) (iv) |
| 1966 | International Covenant on Economic, Social and Cultural Rights: Article 12.1 |
| 1979 | Convention on the Elimination of All Forms of Discrimination against Women: Articles 11 (1) (f), 12 and 14 (2) (b) |
| 1989 | The 1989 Convention on the Rights of the Child: Article 24 |
| 1990 | The International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families: Articles 28, 43 (e) and 45 (c) |
| 2006 | Convention on the Rights of Persons with Disabilities: Article 25. |
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