While the politics and the passions surrounding the global abortion debate endure, it is enlightening to periodically check the rhetoric against the reality of the numbers. The first worldwide review of abortion incidence in eight years shows that the global abortion rate declined modestly during the period. Incidence declined far more in some places than in others, however, and that is where the real story lies.

Between 1995 and 2003, abortion rates dropped more in developed than in developing countries. And although it may be difficult for some to accept, rates fell most sharply in countries where abortion is legally available on broad grounds and widely available in practice. It is in these same places, though, where demand for and use of contraception has been on the rise.

With regard to safety, the news is not so encouraging. Almost half of all abortions around the world are still unsafe, and more than 97% of these unsafe abortions occur in developing countries. At the same time, a number of countries that liberalized their abortion laws in recent years are starting to see real progress in reducing the soaring maternal mortality rates previously associated with clandestine procedures.

It may not be news that liberalizing abortion laws and enabling abortion services to be provided openly by skilled practitioners—even as the society promotes greater contraceptive use—is the most effective way for a country to ensure that abortion is safe for women while simultaneously reducing its incidence. It is nonetheless significant that recent evidence further reinforces the logic of this dual approach. Opponents of abortion in the United States and around the world may be expected to continue to insist that the best way to reduce abortion is to restrict it. With the passage of time, however, more and more countries can now demonstrate the facts to be otherwise.

Abortion Down Where Contraceptive Use Up

According to a major new study by the Guttmacher Institute and the World Health Organization (WHO), published in the Lancet in October, an estimated 42 million abortions took place in 2003—down from 46 million in 1995. Overall, this represents a modest decline in the abortion rate, from 35 per 1,000 women aged 15–44 in 1995 to 29 per 1,000 in 2003. The lowest abortion rates in the world are in Europe, especially Western Europe: For example, the rates for Belgium, Germany and the Netherlands are each below 10. In these countries and throughout most of Europe (as in the United States, where the current abortion rate is 21), abortion is legal and widely available, and contraceptive use is high. By contrast, in Africa, Latin America and the Caribbean, where abortion is highly restricted and contraceptive prevalence is lower, the rates range from the mid-20s to a high of 39.

Between 1995 and 2003, abortion rates decreased or remained basically level in all regions of the world. The sharpest decreases by far occurred in Europe. And although rates fell somewhat throughout the continent, it was the precipitous drop in Eastern Europe that drove the entire continent's decline and, by extension, literally moved the world's abortion rate downward (see chart). The former Soviet bloc countries, such as the Russian Federation, Estonia, Bulgaria and Latvia, still possess the dubious distinction of being home to the world's highest abortion rates. In 2003, 44 abortions occurred in this subregion for every 1,000 women of reproductive age. Significantly, however, that rate was less than half of the 1995 rate of 90.

ALL ABOUT EUROPE
Europe experienced a far more dramatic decline in abortion rates than did other regions of the world, and that decline was concentrated in former Soviet bloc countries.
Source: Lancet, 2007.

Except for a 20-year period under Stalin between 1936 and 1955, abortion has been legal in the Soviet Union since 1920. Until the end of the cold war, it was the only reliable method of fertility control available to most women and was virtually free. Modern contraceptive methods manufactured in the West simply were nonexistent in these countries at the time, and methods manufactured in Soviet bloc countries were so crude that they were unusable. With the fall of the Soviet Union in the early 1990s, availability and acceptance of contraceptive methods increased, and these methods began to replace abortion as the primary means to control fertility. Unlike in many developing countries, a desire for small families was already the norm (as evidenced by the stratospheric abortion rates); therefore, conditions were ripe for a quick transition to contraception.

Many obstacles remain, though, that could impede progress: struggling economies; a historic bias within the medical profession against contraception (much of it based on misinformation about safety and efficacy); financial incentives for physicians to provide abortions in the private sector; and residual social and cultural biases among women themselves, many of whom continue to view abortion as the preferred method of fertility control. Clearly, the shift toward a "contraceptive culture" still has a long way to go; however, if current trends continue, the abortion rates in Eastern Europe may eventually approach those in the West.

Abortion Safest Where Least Restricted

Abortion is generally safe in settings where the procedure is legal and openly available. Where abortion is highly restricted or banned outright, it still occurs, although clandestine; as a result, it is most likely to be unsafe. The WHO defines an unsafe abortion as "any procedure to terminate an unintended pregnancy done either by people lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both." Some unsafe abortions, therefore, take place where the procedure is legal, such as in Eastern Europe and Central Asia (including India), where many practitioners may not be adequately trained, leaving poor women especially vulnerable. Conversely, in the Philippines and in many countries throughout Latin America where abortion is highly restricted, access to safer abortion methods, better trained providers, greater public tolerance for an "underground" network of qualified providers and better access to follow-up care for any postabortion complications can explain why the risks associated with illegal abortion in these countries are now probably lower than they used to be.

Still, the evidence is incontrovertible that the surest way to reduce the death and disability associated with unsafe abortion is to legalize it and bring it into the open. The history of abortion in the United States provides a case in point. The number of abortion-related complications dropped markedly in the United States between 1970 and 1977, with a particularly steep decline in 1973, coinciding with the year the U.S. Supreme Court handed down its Roe v. Wade decision legalizing abortion nationwide. Recent data indicate that less than 0.3% of women having abortions in the United States experience complications requiring hospitalization. In addition, an estimated 400 women died from abortion-related causes in 1960; today, death from abortion is an extremely rare event.

The experiences of South Africa and Nepal offer contemporaneous case examples of the difference that legality and increasingly open provision of abortion services can make. With the fall of apartheid and the adoption of a new constitution, South Africa liberalized its abortion law in 1996. By 2000, according to a study published by the United Kingdom's Royal College of Obstetricians and Gynaecologists, the infection rate attributable to unsafe abortion had already fallen by half compared with 1994. Moreover, the same study reports that maternal deaths plummeted by 91% during this same period. Similarly, Nepal legalized abortion in 2002 in the face of one of the highest maternal death rates in the world. Even though establishing safe abortion services and making them widely available is proving to be a slow process, government hospitals already are reporting a measurable decline in hospitalizations from postabortion complications and in the severity of the complications that do occur.

Greater Priority on Reducing Unsafe Abortion

As the evidence continues to mount that the primary long-term effect of legalizing abortion is to cut the rate of maternal deaths and injuries, official recognition of the moral imperative to reduce maternal mortality has been intensifying. In 2000, 189 countries adopted the United Nations' Millennium Development Goals (MDGs). One of the eight goals is to improve maternal health, with a specific target to reduce the ratio of maternal deaths to live births by three-quarters between 1990 and 2015. Sub-Saharan Africa still lags far behind all other regions in making progress toward this and other targets. In response, health ministers of the African Union convened in a special session last year in Maputo, Mozambique, to focus on universal access to comprehensive sexual and reproductive health and rights. According to the Maputo Plan of Action, "African countries are not likely to achieve the [MDGs] without significant improvements in the sexual and reproductive health of the people of Africa." The plan addresses a wide range of interventions, including reducing the incidence of unsafe abortion by reducing unintended pregnancies, reforming laws and policies, and improving provider training.

Since 1995, when the United Nations Women's Conference in Beijing's Platform for Action called on governments to "deal with the health impact of unsafe abortion as a major public health concern," 17 countries representing all major regions of the world have removed legal restrictions on abortion. Only three have tightened their laws (see table).

In April, the Mexico City legislature voted to liberalize access to abortion for the Federal District (coincident with the city limits, but equivalent to a state). In doing so, this area of almost nine million people (with a total of 19 million living in the greater metropolitan area) became the most populous entity in Latin America, outside Cuba, to allow unrestricted access to safe, legal abortion services during the first three months of pregnancy. "The women of the Federal District are dying from clandestine abortions," argued assembly member Leticia Quezada. "What we want is not one more death, not here, not anywhere."

The new Mexico City law stipulates that abortions will be free in government public health clinics to equalize access. In addition, the law goes to great lengths to couch access to safe abortion in the larger context of "ensuring all persons enjoyment of their right to determine the number and spacing of their children." As described by the Center for Reproductive Rights, the new law states that "sexual and reproductive health care shall be a government priority" and calls for public education toward attaining good sexual and reproductive health and "responsible parenthood." Finally, it is notable that the same law also exhorts the government to provide family planning services "to reduce the incidence of abortion, lower reproductive health risks, prevent sexually transmissible infections, and support the enjoyment of reproductive rights."

Change is in the air elsewhere in Latin America as well. Just last year, Colombia's highest court invalidated a long-standing abortion ban and ruled that abortion must be legal at least to protect a woman's health or life and in cases of rape, incest or severe fetal malformation. In Brazil, President Luis Ignacio "Lula" da Silva has long campaigned for abortion to be seen as a public health issue. Health Minister Jose Gomez Temporao agrees and has joined da Silva in calling for a national referendum to consider legalizing early abortion along the same lines and in the same manner that Portugal, Brazil's former colonizer, did this past July. Meanwhile, he is promoting easier access to contraceptives, including emergency contraception.

As an extension of the public health rationale, reducing the incidence and severity of unsafe abortion is increasingly seen as a matter of human rights. Amnesty International has now taken a stand on the issue after a long review and consultative process among its affiliates worldwide. At its biennial meeting this past August, which by coincidence took place in Mexico City, the renowned human rights organization declared that it would work to "support the decriminalization of abortion, to ensure women have access to health care when complications arise from abortion and to defend women's access to abortion…when their [physical] health or human rights are in danger." This policy is binding upon all country members, including in countries where abortion is illegal.

Moving Forward

Nearly two-thirds of the world's women (64%) live in countries where abortion is generally permissible. One-quarter, however, live where it is severely restricted. This has changed little since 1995, mostly because of the faster population growth in the developing world, which encompasses most of the countries with restrictive laws. However, the Guttmacher-WHO study found that the proportion of abortions worldwide that are unsafe actually increased from 44% to 48% between 1995 and 2003. This is cause for alarm—and more action.

That almost half of all abortions globally are still unsafe points to the huge public health challenge that remains. Now, even more years of real-world experience implicate legal restrictions as a main culprit. The new data on incidence, meanwhile, reinforce what history also shows: that rates decline where abortion is legal and widely available, as long as contraceptive use is rising. More progress can be made, but only if more countries move toward the goal of making abortion legal, so that it will be safe, while promoting contraceptive use, so that there will be less need for abortion. "Safe, legal and rare" was a goal first articulated for the United States by President Clinton as early as 1992. It is still a laudable—and achievable—public policy, public health and humanitarian goal for the world. Meanwhile, as a recent Lancet editorial observes, "for many of the world's most vulnerable women [abortion] remains illegal, unsafe, and common."