From Unsafe to Safe Abortion in Sub-Saharan Africa: Slow but Steady Progress—Executive Summary

This report on induced abortion in Sub-Saharan Africa offers an overview of the legality of abortion and describes how often and how safely abortions occur in the region’s 48 countries. It also examines the underlying context of abortion—namely, unintended pregnancy and its causes. The following are among its principal findings.

Legality of abortion

• The legality of abortion in Sub-Saharan Africa falls along a continuum from prohibited to allowed without restriction as to reason. As of 2019, 92% of the region’s women of reproductive age live in the 43 countries with highly or moderately restrictive laws. These laws either prohibit abortion altogether or restrict it to cases where a woman’s life or health are threatened.
• The African Union’s Maputo Protocol is the only human rights instrument with prescriptive language on abortion criteria. It likely contributed to reform in all countries that added legal grounds since the protocol’s adoption in 2003.
• Since the protocol was passed, seven countries reformed their laws to meet—and in one case, exceed—the African Union’s legal criteria for safe abortion of allowing abortion when the woman’s life or physical or mental health is threatened and in cases of rape, incest and grave fetal anomaly.

Incidence of abortion

• As of 2015–2019, an estimated 33 abortions occur each year per 1,000 women aged 15–49, with little variation across the four subregions of Sub-Saharan Africa. Overall and subregional rates have been relatively stable over the past 25 years.
• However, given Sub-Saharan Africa’s high rate of population growth, an unchanging abortion rate still means increasing numbers of abortions each year. The annual number of abortions nearly doubled between 1995–1999 and 2015–2019, from 4.3 million to 8.0 million.
• Abortion rates in the most populous cities are typically higher than rates in countries as a whole. Moreover, sexually active adolescents have far higher rates of abortion than do all women of reproductive age.
• Global data show that restricting abortion makes no difference in how often it occurs: The annual abortion rate is identical, at 40 per 1,000 women, where abortion is prohibited and where it is broadly legal.

Safety of abortion

• Abortion is riskier in Sub-Saharan Africa than in any other world region: As of 2010–2014, 77% of abortions in the region are unsafe, compared with the global average of 45%. The resulting incidence of unsafe abortion—6.2 million per year—exacts a heavy toll on the region’s women and families.
• Unsafe abortions are the sum of those that are less safe (done by either an untrained person or with a nonrecommended method) and least safe (done by an untrained person using a nonrecommended method). Roughly half of all abortions in the region qualify as least safe; at 69%, this proportion is highest in Middle Africa.
• As of 2019, Sub-Saharan Africa has the highest abortion case-fatality rate of any world region, at roughly 185 deaths per 100,000 abortions, for a total of 15,000 preventable deaths every year. Ongoing efforts to both improve the safety of abortion and expand access to quality postabortion care have likely contributed to a two-fifths decline in this rate since 2000, when an estimated 315 women died per every 100,000 abortions.

Abortion practice and postabortion care

• Several countries that have expanded the legal grounds for abortion have adopted guidelines modeled on international medical standards and now offer safe, facility-based abortions. However, in most Sub-Saharan countries, legal restrictions and stigma still compel women to undergo clandestine abortions, the safety of which cannot be ensured.
• The growing use of misoprostol alone to induce abortion is probably making clandestine abortions safer. This scenario has been documented in Latin America, a region with highly restrictive abortion laws, where use of misoprostol became widespread decades ago.
• Another strategy that can improve outcomes in low-resource settings is to shift postabortion care to midlevel personnel such as nurses and midwives, who are much more numerous than physicians. Postabortion care is always legal, and medical personnel have an ethical duty to provide it.
• Much remains to be done to transition away from dilation and curettage, a highly invasive and costly method of postabortion care, toward the use of misoprostol and vacuum aspiration—methods that meet international guidelines.

Unintended pregnancy and abortion

• Nearly all abortions result from unintended pregnancies. Sub-Saharan Africa has the highest unintended pregnancy rate of any world region, at 91 per 1,000 women—primarily because the region has the highest pregnancy rate overall (218 per 1,000). The proportion of pregnancies reported as unintended is actually lowest in Sub-Saharan Africa, at 42%.
• Once women become pregnant without intending to be, an estimated 37% interrupt such pregnancies. This proportion has risen significantly over the past three decades. Such an increase could seriously affect the well-being of women who face barriers to safe abortion. At the regional level, social stigma remains a persistent barrier; at the national level, barriers can include highly restrictive laws or the inadequate implementation of liberal laws.
• The desire for smaller families is increasing, but in order to have smaller families, women need access to modern contraceptives to limit and space their pregnancies. Should this not occur, many will have unintended pregnancies that they then resolve through abortion. Many of these abortions will be clandestine, and thus likely unsafe, unless the strong stigma attached to abortion—which is reflected in the region’s restrictive laws—is addressed.

The way toward legal and safer abortion is clear—by reducing stigma and expanding legality. But these are only first steps. Reform must be accompanied by political will and full implementation of the law, so that all women—despite inability to pay or fear of stigma—can seek and receive a legal, safe abortion.

In countries with few or no legal grounds for abortion, mitigating the harm of unsafe abortion becomes the priority. The declines in abortion-related deaths demonstrate the benefits of expanding the reach and quality of postabortion care. The increasing use of misoprostol to induce abortion is likely also saving lives. Clandestine abortion can be made safer through harm reduction initiatives that have worked elsewhere, such as disseminating accurate information on how to use misoprostol. In every Sub-Saharan African country, expanding modern contraceptive use will go a long way toward reducing unintended pregnancies and subsequent unsafe abortions.