The situation of induced abortion has changed markedly over the past few decades. This report provides updated information on the incidence of abortion worldwide, the laws that regulate abortion and the safety of its provision. It also looks at unintended pregnancy, its relationship to abortion, and the impact that both have on women and couples who increasingly want smaller families and more control over the timing of their births.
Induced abortion is common across the globe. The vast majority of abortions occur in response to unintended pregnancies, which typically result from ineffective use or nonuse of contraceptives. Other factors are also important drivers of unintended pregnancy and the decision to have an abortion. Some unintended pregnancies result from rape and incest. Other pregnancies become unwanted after changes in life circumstances or because taking a pregnancy to term would have negative consequences on the woman's health and well-being. As a result, abortion continues to be part of how women and couples in all contexts manage their fertility and their lives, regardless of the laws in their country. Thus, safe abortion services will always be needed.
We also assessed the situation through the lens of gross national income, using the World Bank's classification of countries into four income groups.k The proportions of women living in countries where abortion is most broadly legal rises consistently with income, from 19% in low-income countries to 80% in high-income countries (Figure 3.2). Relatedly, the pattern reverses for the most restricted category: Less than 0.05% of women in high-income countries live where all abortions are prohibited, compared with 17% in low-income countries.
When provided by a trained practitioner in an environment that meets minimum medical standards, an abortion is a safe medical procedure with an extremely low likelihood of complications.100 To assure this high level of safety, WHO developed101 and later updated36 guidelines for the provision of safe abortions, which cover each component of comprehensive abortion care. A separate set of recommendations identifies the personnel appropriate to each task involved (Table 5.1).32
Care should start with confidential, nondirective counseling on all reproductive options, so women fully understand what to expect, can freely decide whether to have the abortion and can be secure about that decision. And as with all medical procedures, abortion patients benefit from counseling about follow-up care, especially to ensure that women know what action to take should complications arise. For the very small group of women who do experience complications, WHO guidelines detail recommended treatments.
To ensure the broadest possible availability of abortion in the first trimester (when abortions are safest), WHO recommends that in contexts in which doing so would expand access and reduce costs, abortions be provided by trained midleveln personnel instead of doctors, and at primary rather than higher-level facilities (see Table 5.1). These recommendations are based on evidence showing no difference in safety or efficacy by type of trained provider (and whether the abortion is done in a primary or higher-level health facility).32,104
Given that the vast majority of induced abortions occur because of an unintended pregnancy, WHO guidelines emphasize that contraceptive counseling and method provision be integrated into comprehensive abortion care.105 If women wish to do so, they should be able to obtain a contraceptive method where they receive abortion care, which eliminates the need for referral to another source of care. Furthermore, it is crucial that women who want to use a contraceptive method are offered a wide range of choices, that women who have experienced method failure be given the option to switch, and that all women can freely choose a method based on their preferences and needs.
Available data from legally restrictive settings show increases in the use of vacuum aspiration, which is a less-invasive surgical technique than D&C. Perhaps even more important, use of misoprostol alone (the second drug in the combination protocol) has risen substantially.37,63 In countries that legally restrict abortion, mifepristone (the first drug) is either prohibitively expensive or unavailable altogether. Misoprostol, which is widely registered to treat gastric ulcers (and less-widely registered for obstetric indications), is far less expensive than mifepristone and much more available110,111 (see misoprostol-only box).
Information on trends in abortion methods used in legally restrictive settings is available for just three countries: Colombia and Mexico (between 1992 and 2008), and Pakistan (between 2002 and 2012). Data on misoprostol use were not collected for the earlier years in Colombia and Mexico because its use was considered to be very limited at that time. According to surveys of health professionals, an estimated one-half of all abortions in Colombia in 2008 and nearly one-third in Mexico in 2007 were done using misoprostol alone. At the same time, the proportions of procedures performed by physicians and untrained providers have declined, which suggests that reliance on surgical methods and unsafe traditional methods have both dropped.112 In Pakistan, the proportion of health professionals who responded that misoprostol was commonly used was much higher in 2012 than in 2002, and this change was more evident in urban areas than in rural areas.113
The abortion-provision picture is mixed for the countries that liberalized their laws within roughly the past two decades (Figure 3.3). One of the first challenges to instituting safe services is communicating that abortion is now legal and where it is available. Informing health professionals and women of a newly granted right is an enormous challenge, especially where rates of illiteracy and poverty are high, and where abortion continues to be strongly stigmatized. The fact that many countries have unclear laws and service provision guidelines that sometimes conflict with the law makes this challenge even more difficult to overcome.
Access to legal abortion can be impeded if large numbers of providers claim conscientious objection, which in the absence of efficient referral systems can translate to delays, in turn leading to riskier procedures at later gestations, or even the denial of legal care.121 Greater acceptability of medication abortion could help address this barrier to timely care, especially right after legal reform when health professionals are expected to transition to provision of a new service.122 In fact, evidence from several countries shows that health professionals may be more willing to provide medication abortion than surgical abortion, because they are more removed from the process of the abortion itself.123
Sometimes, safe services can coexist with clandestine and unsafe ones years after liberalization. In Ethiopia,o for example, only a little over half (53%) of abortions in 2014 were legal procedures about nine years after law reform; nevertheless, that constituted significant progress as the level in 2008 was about half that (27%).125 In Nepal, which enacted more sweeping legal change than any other country since 2000, 63% of health facilities provided legal abortions as of 2014, and 42% of all abortions that year were legal.95 Barriers to safe abortion care that persist in Nepal include women's inadequate knowledge of its legality and of where to obtain services; poor availability, especially in rural areas; long distances to health facilities; and high costs, despite legislation ensuring the contrary.
The institutional framework of service delivery also varies markedly across countries where abortion is broadly legal. For example, in some countries, clinics that specialize in providing abortions can be the main or sole source of abortion care, whereas in others, abortion can be offered as one of an integrated range of reproductive health services. In addition, countries vary in the extent to which abortion services are provided by public, private and nongovernmental-organization facilities.
The specific methods of abortion used in broadly legal countries have undergone a sea change since mifepristone was approved, starting with China and France in 1988.110 By about the mid-2000s, combination medication abortions outnumbered surgical procedures in several countries, including Finland, France and Sweden (Figure 4.2). However, use of the surgical D&C procedure, which is no longer recommended by WHO, was still common in some former Soviet Bloc and satellite countries: In Armenia, nearly six out of 10 abortions in 2010 were by D&C, as were three out of 10 that year in Georgia129 and four out of 10 in Belarus in 2013.130
Small-scale studies in Nepal, South Africa and Tunisia found that women are sometimes denied care even when they legally qualify for an abortion.33 Some of these women were turned away because they could not pay for their abortions; others because the clinics lacked the staff or equipment to perform the abortion, or required the woman to first undergo unnecessary laboratory tests. Women denied services might obtain referrals and receive legal abortions elsewhere, but they may also turn to unsafe abortions from untrained providers or continue with an unwanted pregnancy.
Its use is now common in much of Latin America and the Caribbean, a region in which nearly every country has highly restrictive abortion laws. Limited national-level data from surveys of health professionals and others familiar with abortion suggest that misoprostol alone was used in an estimated 30% of abortions in Mexico (2007)9 and in half of those in Colombia (2008).10 A survey using two methodological approaches similarly found that half of abortions in urban Brazil (2010) involved misoprostol alone.11 Postabortion care studies also provide a glimpse into the methods that women use, although by definition, these exclude women who did not need or were unable to reach care. In Gabon in 2008, for example, some two-thirds of postabortion care patients at the major hospital in the capital city had used misoprostol,12 as had nearly three-fifths in the second-largest hospital in Ghana in 2010.13 2b1af7f3a8