Much of Sub-Saharan Africa is undergoing broad societal transformation, with improvements in standards of living, educational attainment and health. Yet, the region continues to have the highest estimated proportion of unsafe abortions in the world because of legal restrictions and stigma. It also has the most maternal deaths per 100,000 abortions. These deaths are preventable and point to an urgent need for high-quality postabortion care and safer abortions. Improved modern contraceptive services would prevent the unintended pregnancies that lead to abortions to begin with.

Incidence and trends in abortion

• An estimated 33 abortions occur annually per 1,000 women aged 15–49, with little variation across Eastern, Middle, Southern and Western Africa.^* This rate has remained largely unchanged over the past two decades.
• But as a result of population growth, the annual number of abortions in Sub-Saharan Africa almost doubled between 1995–1999 and 2015–2019, from 4.3 million to 8.0 million.
• Abortion rates are elevated among women in large cities and among 15–19-year-olds who have had sex in the past year.

Legal status of abortion

• The vast majority—92%—of women of reproductive age (15–49) in the region live where abortion is highly or moderately restricted.
• In 2003, the African Union adopted a women’s rights charter, the Maputo Protocol, whose Article 14 states that abortion must be legal to save a woman’s life and preserve her physical or mental health, and in cases of rape, incest and grave fetal anomaly. Since then, seven Sub-Saharan countries have reformed their laws to meet—and in one case, exceed—these minimum criteria.
• In total, 21 out of the 48 Sub-Saharan countries expanded the grounds on which abortion is legal between 2000 and 2019.

Unsafe abortion

• In Sub-Saharan Africa, more than three-quarters (77%) of abortions are estimated to be unsafe—that is, they are done by an untrained person, done using a nonrecommended method or both.
• As of 2019, some 6.2 million unsafe abortions occur in the region per year. They exact a heavy toll on individuals, families and health systems.
• Sub-Saharan Africa has the highest rate of abortion-related deaths in the world, at 185 maternal deaths per 100,000 abortions. Nonetheless, this represents a two-fifths decline since 2000, which occurred in part because of improvements in abortion safety and postabortion care.

Unintended pregnancy and abortion

• Sub-Saharan Africa has the highest pregnancy rate of any world region (218 per 1,000 women per year). Thus, the region has the highest unintended pregnancy rate (91 per 1,000), despite having the lowest proportion of pregnancies that are unintended (42%).
• Among women who become pregnant without intending to be, an estimated 37% terminate the pregnancy.
• From 1990–1994 to 2015–2019, the share of unintended pregnancies resolved through abortion increased by 26% in Middle Africa, by 44% in both Eastern and Western Africa and by 72% in Southern Africa.

Recommendations

Improving sexual and reproductive health care benefits societies, and expanding the reach of postabortion care services to all women in Sub-Saharan Africa who need them is crucial. Reducing the need for postabortion care by improving the safety of abortions in the first place will require sustained collaboration from all stakeholders to implement legal criteria that, at a minimum, meet the requirements of the Maputo Protocol.

• The legal criteria in the Maputo Protocol provide a blueprint for advocates and policymakers working to improve women’s health. Out of the 39 Sub-Saharan countries that have ratified it, only 15 are fully compliant with all of the protocol’s grounds for abortion.
• Legality alone does not ensure availability of and access to quality abortion services. Reform must be accompanied by full implementation, so that all women who qualify for a legal abortion are able to obtain one safely.
• Women will seek abortion no matter its legal status. Continued investment in improving postabortion care is necessary to mitigate the harm caused by unsafe clandestine abortions. 
• In countries with few or no legal grounds for abortion, the health effects of unsafe abortion can be minimized by promoting initiatives that have worked elsewhere, such as disseminating accurate information on how to use misoprostol alone, a relatively inexpensive variation of the combination medication protocol.
• Preventing unintended pregnancy through expanded access to modern contraception will go a long way toward reducing the need to resort to abortion.