The substantial decline in abortion rates that occurred in both developed and developing regions of the world between 1995 and 2003 stalled out between 2003 and 2008. According to a new study by the Guttmacher Institute and the World Health Organization, published in The Lancet, this plateau mirrors a leveling off of contraceptive use during the same period.^1,2 Overall, almost 44 million abortions took place worldwide in 2008, but the proportion occurring in developing countries rose from 78% to 86%, in part because of the increase in the proportion of women of reproductive age living there.¹ This trend has significant public health implications, because abortion in the developing world is largely illegal and often medically unsafe. Indeed, the new study concluded that in 2008, about half of all abortions performed globally were performed by untrained providers or in unsanitary conditions or both.

Both the lowest and the highest rates of abortion can be found in a single region: Europe. The countries with the lowest rates are in Western Europe, where the rate is 12 per 1,000 women ages 15–44. At the other end of the spectrum is Eastern Europe, where the abortion rate is 43 per 1,000. Notably, where abortion rates are the lowest, it is broadly legal and widely available and use of effective contraceptive methods is widespread. By stark contrast, while the status of abortion law throughout most of Eastern Europe is essentially similar to that in the west, contraceptive use is low and the methods women do use are more likely to be condoms, withdrawal and the rhythm method—all of which tend to be associated with high failure rates due to incorrect or inconsistent use.

In between the extremes of Eastern and Western Europe fall Latin America, Africa and Asia, where the abortion rates are 32, 29 and 28 per 1,000, respectively. In these regions of the world, where the status of legal abortion varies, levels of contraceptive use are the strongest predictor of abortion incidence. Within Africa, for example, the rate is highest in eastern Africa, where abortion is mostly illegal and approximately one in four women who want to avoid a pregnancy in the next two years are not using a method of contraception.² It is lowest in southern Africa, where the rate is only 15 per 1,000. This is a subregion that is dominated by South Africa, which legalized abortion in 1996 and where only 15% of women have an unmet need for contraception.

While abortion rates in the developing world vary widely, unsafe abortion procedures and conditions are pervasive, since most abortions in these regions are clandestine. Fully 97% of all abortions taking place in Africa are medically unsafe, as are 95% of those in Latin America and 40% in Asia.¹ Unsafe abortion accounts for 13% of all maternal deaths each year and virtually all of those deaths—47,000—occur in the developing world. More than eight million women suffer from complications of unsafe abortion that are serious enough to warrant medical treatment.

As a whole, this new body of evidence reinforces the enduring and universal truths that unintended pregnancy is the primary determinant of abortion rates and that abortion's legal status has much more to do with whether it is performed by trained providers and in sanitary conditions than it has to do with how frequently it occurs. These findings should compel policymakers to increase the global investment to help women obtain and effectively use contraceptive services so they can prevent unintended pregnancy. The findings also argue for making access to safe abortion services a high priority, including encouraging the global trend toward liberalization of abortion laws to create conditions conducive to providing safe services. —Susan A. Cohen

REFERENCES

1. Sedgh G et al., Induced abortion: incidence and trends worldwide from 1995 to 2008, Lancet, 2012, 379(9816):625–632, <http://www.guttmacher.org/pubs/journals/Sedgh-Lancet-2012-01.pdf>, accessed Feb. 17, 2012.

2. Department of Economic and Social Affairs, Population Division, United Nations, World contraceptive use 2010, 2011, <http://www.un.org/esa/population/publications/wcu2010/WCP_2010/Data.html>, accessed Dec. 19, 2011.