Abstract
There are significant variations in the legalisation, restrictions and legal abortion rates worldwide. This undoubtedly influences the provision and accessibility to abortion services. Although there have been changes to the laws in several countries over the last decade, this has not yet been translated into practice in the provision of safe abortion in these countries. In countries where abortions are permitted without restriction; the majority of abortions are carried out by trained practitioners in approved facilities. In contrast, in countries where restrictions are imposed, the majority of abortions performed are considered to be unsafe and therefore associated with significant morbidity and mortality. This article discusses the most recent data available regarding worldwide legal abortion rates, trends over the last ten years and issues related to specific regions which may influence the provision of safe abortion services in the future.
Introduction
Since the late 1990s a significant number of global changes have occurred which have huge implications for the prevalence and safety of abortion. Contraceptive use has become more widespread particularly in Asia and Latin America and there has been growth in the use of less invasive methods of abortion such as manual vacuum aspiration and medical abortion.
In addition to the liberalization of laws in several countries, access to safe abortion in developing countries with legal restrictions appears to be growing. Some of this improved access may be attributable to the growing use of medical abortion.
Continued campaigning from several global, international and regional organizations has also drawn attention to the importance of making safe abortion services widely accessible where they are legal and trying to reduce the burden of morbidity and mortality by reducing the number of unsafe abortions.
The International Conference on Population and Development which was held in 1994 called upon governments to strengthen their commitment to women’s health. It recommended that there should be access to safe abortion services in countries where abortion is legal. Furthermore there should be provision for high quality services to manage abortion complications, offer counseling, education and contraception.
In 2000, eight Millennium Development Goals were set by the United Nations. Maternal Health was one of these goals and key targets were set to achieve universal access to reproductive health care and reduce maternal mortality by 70% by 2015. It was emphasised by the report that a reduction in maternal mortality cannot be achieved without addressing the issue of unsafe abortion.
In 2003, the WHO published international standards and guidelines for safe abortion care . The International Federation of Gynecology and Obstetrics stated that women everywhere should have the right to safe, effective and affordable methods of contraception and safe abortion services . This organisation is responsible for a major initiative on these issues.
Variations in abortion laws worldwide
There is a wide variation in the laws governing abortion around the world. These are summarized below but a full breakdown can be found in Appendix 1 of .
There is an important caveat to this categorization, as the way that a law is written and the way that it is implemented practically, may not always overlap. In the majority of more developed countries where abortion is legal, there are safe and accessible services. This may not always apply in some less developed countries where services are non-existent or inadequate and therefore the written law is irrelevant. In countries where legal restrictions are in place, there is usually little provision of safe abortion services even for women who could obtain a legal abortion on the narrow grounds permitted. Conversely, the restrictive laws in some countries are not actively enforced.
Countries with the most restrictive laws
The 32 countries in this category, where abortion of any kind is illegal, is inhabited by 6% of all women of childbearing age which equates to 7% of all women living in less developed countries, but only 0.1% of women living in more developed countries. Whilst the wording of the laws in these countries does not include any explicit exceptions, such as to save the life of the woman, or in cases of rape, incest or fetal impairment, in 28 of these countries the law could be interpreted as to permit an abortion on the grounds of necessity. It is virtually impossible to gather information as to how often, if ever, appeal on these grounds is granted.
There are 36 countries where abortion is permitted to save the life of the pregnant woman and in some cases of rape or other extenuating circumstances. 21% of women of childbearing age and 25% of such women in developing countries are subject to these restrictions worldwide . The only developed country in this category is Ireland.
Countries with less restrictive laws
The next two categories, which include laws permitting abortion to save a woman’s life or preserve physical health and more explicitly to preserve her mental health, are observed in 59 countries. This accounts for a further 14% of all women of childbearing age and 15% of those in less developed regions . Not surprisingly, the laws in these countries are subject to wide variation in interpretation and implementation.
A further 14 countries allow abortion under the previously mentioned grounds and also for socioeconomic grounds. This category includes India, which has a population of more than one billion, and therefore there are a disproportionately large number of women from less developed countries in this category (22% compared with 17% from more developed countries). Interestingly, although India does not have particularly restrictive laws, it is estimated that only two out of five abortions would be considered safe using WHO criteria.
Countries with liberal abortion laws
Abortion is legal in 56 countries without restriction as to reason. The inclusion of China in this category translates to 39% of women of childbearing age worldwide being in this group. This is subdivided into 31% of those in the less developed world and 76% of those in the more developed world.
Although in these countries abortions can be granted without restriction as to reason, there are several other limitations which are imposed. These most commonly include restriction by gestation, commonly before 12 weeks. Where the gestation limits are higher, further requiremets often need to be met. In some countries women are required to have parental consent if aged under 16, or spousal consent if married. China and Nepal both also ban abortion for purposes of sex selection.
There is a stark contrast between the proportion of women of childbearing age living in more developed countries with highly restrictive laws on abortion (7%) (banned altogether or only permitted to save a woman’s life, protect her physical or mental health, or in cases of rape, incest or fetal impairment) and less developed countries (47%). This contrast is made even starker, when China and India are removed from the figures; more than 86% of women living in less developed countries are subject to highly restricted abortion laws.
In countries with highly restrictive laws, it is likely that very few women will be able to access safe abortion even on permitted grounds, as government-assisted services are usually not supported and therefore services are only available to those who can afford to pay the relatively few trained private doctors. In exceptional cases, e.g. Uruguay, the government has enacted an ordinance permitting special counseling service in government facilities. These services are part of a framework based on a woman’s right to health, autonomy, full information and patient-provider confidentiality. Whilst this service is unable to provide safe abortion, once a pregnancy is medically confirmed and the woman expresses an intention to have an abortion, information regarding safe methods using misoprostol is given. The drug is not prescribed, but women are advised to come back to the facility after using the drug to confirm that the pregnancy has ended.
As previously discussed, several less developed countries have liberal abortion laws. China were the first large developing country to introduce such a law in 1957 and since then The Soviet Union, the Central and Western Asian republics, Cambodia, Cuba, India, Mongolia, Singapore, South Africa, Taiwan, Tunisia, Turkey, Vietnam, and Zambia followed suit. Unfortunately, despite liberal legislation legal, safe abortion is not widely accessible in South Africa, India, Cambodia and Zambia.
Variations in abortion laws worldwide
There is a wide variation in the laws governing abortion around the world. These are summarized below but a full breakdown can be found in Appendix 1 of .
There is an important caveat to this categorization, as the way that a law is written and the way that it is implemented practically, may not always overlap. In the majority of more developed countries where abortion is legal, there are safe and accessible services. This may not always apply in some less developed countries where services are non-existent or inadequate and therefore the written law is irrelevant. In countries where legal restrictions are in place, there is usually little provision of safe abortion services even for women who could obtain a legal abortion on the narrow grounds permitted. Conversely, the restrictive laws in some countries are not actively enforced.
Countries with the most restrictive laws
The 32 countries in this category, where abortion of any kind is illegal, is inhabited by 6% of all women of childbearing age which equates to 7% of all women living in less developed countries, but only 0.1% of women living in more developed countries. Whilst the wording of the laws in these countries does not include any explicit exceptions, such as to save the life of the woman, or in cases of rape, incest or fetal impairment, in 28 of these countries the law could be interpreted as to permit an abortion on the grounds of necessity. It is virtually impossible to gather information as to how often, if ever, appeal on these grounds is granted.
There are 36 countries where abortion is permitted to save the life of the pregnant woman and in some cases of rape or other extenuating circumstances. 21% of women of childbearing age and 25% of such women in developing countries are subject to these restrictions worldwide . The only developed country in this category is Ireland.
Countries with less restrictive laws
The next two categories, which include laws permitting abortion to save a woman’s life or preserve physical health and more explicitly to preserve her mental health, are observed in 59 countries. This accounts for a further 14% of all women of childbearing age and 15% of those in less developed regions . Not surprisingly, the laws in these countries are subject to wide variation in interpretation and implementation.
A further 14 countries allow abortion under the previously mentioned grounds and also for socioeconomic grounds. This category includes India, which has a population of more than one billion, and therefore there are a disproportionately large number of women from less developed countries in this category (22% compared with 17% from more developed countries). Interestingly, although India does not have particularly restrictive laws, it is estimated that only two out of five abortions would be considered safe using WHO criteria.
Countries with liberal abortion laws
Abortion is legal in 56 countries without restriction as to reason. The inclusion of China in this category translates to 39% of women of childbearing age worldwide being in this group. This is subdivided into 31% of those in the less developed world and 76% of those in the more developed world.
Although in these countries abortions can be granted without restriction as to reason, there are several other limitations which are imposed. These most commonly include restriction by gestation, commonly before 12 weeks. Where the gestation limits are higher, further requiremets often need to be met. In some countries women are required to have parental consent if aged under 16, or spousal consent if married. China and Nepal both also ban abortion for purposes of sex selection.
There is a stark contrast between the proportion of women of childbearing age living in more developed countries with highly restrictive laws on abortion (7%) (banned altogether or only permitted to save a woman’s life, protect her physical or mental health, or in cases of rape, incest or fetal impairment) and less developed countries (47%). This contrast is made even starker, when China and India are removed from the figures; more than 86% of women living in less developed countries are subject to highly restricted abortion laws.
In countries with highly restrictive laws, it is likely that very few women will be able to access safe abortion even on permitted grounds, as government-assisted services are usually not supported and therefore services are only available to those who can afford to pay the relatively few trained private doctors. In exceptional cases, e.g. Uruguay, the government has enacted an ordinance permitting special counseling service in government facilities. These services are part of a framework based on a woman’s right to health, autonomy, full information and patient-provider confidentiality. Whilst this service is unable to provide safe abortion, once a pregnancy is medically confirmed and the woman expresses an intention to have an abortion, information regarding safe methods using misoprostol is given. The drug is not prescribed, but women are advised to come back to the facility after using the drug to confirm that the pregnancy has ended.
As previously discussed, several less developed countries have liberal abortion laws. China were the first large developing country to introduce such a law in 1957 and since then The Soviet Union, the Central and Western Asian republics, Cambodia, Cuba, India, Mongolia, Singapore, South Africa, Taiwan, Tunisia, Turkey, Vietnam, and Zambia followed suit. Unfortunately, despite liberal legislation legal, safe abortion is not widely accessible in South Africa, India, Cambodia and Zambia.
Regional changes to abortion laws over last decade
Africa
In 2005, Swaziland approved a constitution that allows abortion to save a life of the woman, in cases of serious threat to physical or mental health and on the grounds of rape, incest or fetal impairment. Four other African countries (Benin, Chad, Niger, Togo) now permit abortions on the grounds of physical health and in cases fetal impairment. Ethiopia, Guinea, Benin and Togo also added exceptions for rape and incest, as did Mali which authorized legal abortions to save the life of the pregnant woman for the first time in 2002 .
Asia
Cambodia and Nepal made highly significant changes to their abortion laws by permitting abortion without restriction as to reason from their previously highly restrictive legislation allowing life saving abortions only. Bhutan authorized abortions to save the life of a pregnant woman and in cases of rape and incest, and in 2005 Thailand added the protection of a woman’s mental health as a legitimate justification. Iran also radically changed their law by allowing abortions in the first four months for fetal impairment and in cases where the “life of the pregnant woman is endangered”.
In Indonesia, legislation which would expand the criteria for legal abortion to include medical emergency has been presented several times to the parliament and president. To date, however, this legislation has still not been passed.
Europe
Portugal and Switzerland relaxed their restrictions to allow abortion without restriction as to reason. In contrast, Poland increased their restrictions by withdrawing socioeconomic reasons as a legal ground.
Latin America and Caribbean
Mexico’s Federal District made a significant change by relaxing their laws to permit abortion without restriction as to reason. Columbia also authorized abortion as a life saving procedure and in cases of serious threat to physical or mental health, rape, incest or fetal impairment. St Lucia amended its laws to allow legal abortion on similar grounds in 2004. Since 1997, however, El Salvador and Nicaragua have amended their penal codes to eliminate all exceptions to the prohibition of abortion. In El Salvador it had previously been permitted to save a woman’s life and in cases of rape or fetal impairment and in Nicaragua it was allowed for therapeutic purposes after the approval of three physicians. In Latin America, the political debate is still ongoing. 13 of Mexico’s 31 states have recently amended their constitutions to protect the fetus in utero and in Uruguay, although the legalisation of first trimester abortion was given approval by the legislature, it was vetoed by the president.
Oceania
In some states in Australia (Tasmania, Central Territory, Victoria and Western Austalia) the law has been changed to permit abortion to protect the physical or mental health of the pregnant woman.
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