An estimated 215 million women in the developing world have an unmet need for modern contraceptives, meaning they want to avoid or delay a pregnancy but can’t access contraception – and 82% of unplanned pregnancies in developing countries occur among these women . It should also be noted that these figures only include women who are married or living in marriage-like relationships, and therefore may not include pregnancies among younger or uncoupled women subjected to sexual violence or non-consensual sex, for example.
A large proportion of abortions that happen every year are unsafe, defined by the World Health Organisation (WHO) as being either performed by someone without the necessary skill to do a procedure safely, or being performed in unhygienic conditions, or both .
The vast majority of these are in developing countries, where access to contraceptives and safe, legal abortion is extremely difficult for some women.
The World Health Organisation estimates that 21.6 million unsafe abortions took place internationally in 2008, or that one in ten pregnancies worldwide ended in unsafe abortion .
Around 47,000 women are estimated to have died from unsafe abortion in 2008, meaning 13% of maternal deaths worldwide are attributed to unsafe abortion .
As well as the tens of thousands of deaths of women each year, 2005 estimates indicate that unsafe abortion results in the temporary injury or permanent disability of 8.5 million women around the world annually, and that three million of these women are unable to access medical assistance for this .
The impact of unsafe abortion extends to the existing children of these women, who also often experience increased poverty, compromised health and death.
Women experience unplanned pregnancy for many reasons, including forced intercourse, difficulties in access to preferred methods of contraception (see above), incorrect use and inadequate quality of contraceptives, contraceptive failure, and a lack of empowerment to achieve control of their sexual and reproductive lives – a view shared by the WHO:
It is likely that the numbers of unsafe abortions will continue to increase unless women’s access to safe abortion and contraception – and support to empower women (including their freedom to decide whether and when to have a child) – are put in place and further strengthened .
Poverty is a major reason women turn to abortion, when they consider coping with the financial impact of an unplanned pregnancy.
Health risks to themselves and/or the fetus are another major concern, including HIV/AIDS risks and inadequate pre- and post-maternal care. Inadequate maternal care is prevalent in developing countries ; the high incidence of obstetric fistula is a prime example of the consequences of poor maternity care.
Relationships and support, size of families and number of children are also issues. In countries where the infant mortality rate is high, it is estimated that the ability to space children two years apart increases the second child’s survival rate by 50% .
Highly restrictive abortion laws are not associated with lower abortion rates. It is estimated that the abortion rate is 29 per 1,000 women of childbearing age in Africa and 32 per 1,000 in Latin America—regions in which abortion is illegal under most circumstances in the majority of countries. The rate is 12 per 1,000 in Western Europe, where abortion is generally permitted on broad grounds .
In countries where abortion law is restrictive, large numbers of hospital beds are occupied by women who have experienced complications from clandestine, unsafe abortions. High death and infection rates reflect the reliance on unqualified providers. Self-induced methods used include drinking poisonous substances or high doses of over-the-counter drugs, inserting objects and substances into the uterus (sticks, wire, bleach) and physical trauma (punches, falls). These methods often fail and also cause serious injury. Complications include incomplete abortion, infection, heavy blood loss and cervical trauma.
Other impacts of restrictive abortion laws include corruption of law enforcement (bribes from backyard operators), doctors working in uncertainty which creates further access issues, and discrimination (only wealthy women can access abortion).
Where abortion is generally permitted, it is generally safe, and where it is highly restricted, it is typically unsafe. In South Africa, the annual number of abortion-related deaths fell by 91 % after the liberalization of the abortion law in 1996 .
Where abortion law is not restrictive, women may still have difficulty in accessing safe abortion, such as in India where although abortion is fully legal, many rural women and/or women living in poverty cannot access a certified clinic facility.
In some countries where abortion is prohibited by law, women with sufficient funds travel to an alternate country. It is estimated that 6000 Irish women access abortion in Britain per year .
Legal access to abortion across the world ranges from unrestricted to totally restricted. Access also varies across state jurisdictions, such as in the United States and here in Australia. Countries that permit abortion on request or for a broad variety of reasons are home to almost 60% of women of reproductive age and Britain, Canada, China and South Africa. Countries that totally prohibit abortion, or permit abortion only to save the life of the woman, contain around 20% of the women of reproductive age and include Indonesia, the Phillippines, Chile, Iran, Sudan, Kenya and Nigeria .
Some countries permit abortion for rape or incest. Often inadequate referral pathways exist to refer a women who has been treated for rape for an abortion procedure. With the underlying societal difficulties in many countries and situations, where women have poor access to reporting and obtaining treatment for rape, and little power in negotiating safe and consensual sex, this law does not facilitate access to safe abortion.
Many countries where abortion is restricted also require the consent of the woman’s husband to the procedure .
The past twenty years have seen a trend towards the liberalisation of abortion law, including many jurisdictions such as South Africa, Switzerland, Cambodia, Ethiopia and Mexico City .
It is hoped that wider access to medication abortion, as well as antibiotics, will reduce the number of unsafe abortions.
Continued action in reforming restrictive law, women’s social and economic conditions, and reproductive health education is important in improving women’s health across the world. Continued research in reproductive health issues and advocacy for women’s rights underpins these initiatives.
S Singh et al., Adding It Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health, New York: Guttmacher Institute, 2009. Available online at http://www.guttmacher.org/pubs/FB-AIU-summary.pdf.
Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008 Sixth edition. World Health Organisation, 2011. Available online at http://whqlibdoc.who.int/publications/2011/9789241501118_eng.pdf.
Facts on Induced Abortion Worldwide Published by the Alan Guttmacher Institute, January 2012. Available online at http://www.guttmacher.org/pubs/fb_IAW.html.
T Houweling, C Ronsmans, O Campbell, A Kunst ‘Huge poor–rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries’ Bulletin of the World Health Organization, Volume 85, Number 10, October 2007, 733-820. Available online at http://www.who.int/bulletin/volumes/85/10/06-038588/en/.
Data from USAid publication Birth Spacing: A call to action Available online at http://www.usaid.gov/our_work/global_health/pop/publications/docs/birthspacing.pdf.
A Rahman, L Katzive, SK Henshaw ‘A Global Review of Laws on Induced Abortion, 1985-1997’ International Family Planning Perspectives Volume 24, Number 2, June 1998. Available online at http://www.guttmacher.org/pubs/journals/2405698.html.