After a period of substantial decline, the global abortion rate has stalled, but the proportion of unsafe abortions continues to rise. These are among the findings of new research from the Guttmacher Institute and WHO, published Online First by The Lancet.
Between 1995 and 2003 the abortion rate per 1000 women of childbearing age (15 years) worldwide dropped from 35 to 29; the new study found that in 2008 the global abortion rate was 28 per 1000, virtually unchanged since 2003. Alarmingly, the proportion of abortions deemed as unsafe rose from 44% in 1995 to almost half (49%) in 2008.
Unsafe abortion is defined by WHO and the authors of the report as a procedure for terminating a pregnancy that is performed by an individual lacking the necessary skills, or in an environment that does not conform to minimal medical standards, or both. Estimates were based largely on nationally representative surveys, official statistics, hospital records, and other published studies. Adjustments were made to account for underreporting and misreporting in these information sources. About 78% of all abortions took place in the developing world in 1995. This had increased to 86% by 2008, whereas the proportion of all women of reproductive age who live in the developing world rose more slowly from 80% to 84% in the same interval.
Despite the decline in the abortion rate, there were 2.2 million more abortions in 2008 (43.8 million) compared with 2003 (41.6 million), due to the increasing global population. Since 2003, the number of abortions fell by 0•6 million in the developed world, but increased by 2•8 million in developing countries.
In developed countries (excluding eastern Europe), the abortion rate fell slightly from 19 per 1000 women in 2003 to 17 in 2008. In the developing world, the rate remained constant at 29 in both years. In 2008, the lowest subregional rate worldwide was in western Europe (12) and the highest was in eastern Europe (43). The rate in Oceania dropped from 21 in 1995 to 18 in 2003, and hardly changed to 17 in 2008. There was also a small but steady decrease in North America, from 22 (1995) to 21 (2003) then 19 (2008), although the change from 2003 to 2008 was not statistically significant for Europe or North America. After falling from 33 to 29 from 1995 to 2003, Africa's rate remained static at 29 in 2008.
The proportion of unsafe abortions rose steadily across the 13 years, from 44% in 1995, to 47% in 2003, and to 49% in 2008. Nearly all (97%) abortions were unsafe in Africa in 2008. The proportions of abortions that are unsafe vary widely across Asia, from a negligible proportion in eastern Asia to 65% in south central Asia. Almost all (>99%) abortions in North America and Europe (excluding Eastern Europe) were deemed safe. In eastern Europe, 13% of abortions were unsafe in 2008.
The estimated worldwide proportion of pregnancies that end in abortion has been fairly stable over time, at 22% in 1995, 20% in 2003, and 21% in 2008. In the developed world, abortion declined as a proportion of all pregnancies from 36% in 1995, to 26% in 2008. It held steady at 19% of pregnancies in the developing world.
The authors note also that in 2008, the abortion rate was lower in subregions where large proportions of the female population lived under liberal laws than in subregions where restrictive abortion laws prevailed. For example, the abortion rate is 29 per 1000 women of childbearing age in Africa and 32 per 1000 in Latin America—regions in which abortion is illegal under most circumstances in the majority of countries. The rate is 12 per 1000 in Western Europe and 19 in North America, where abortion is generally permitted on broad grounds. The authors highlight liberalisation of abortion laws in South Africa, Nepal, and more recently Ethiopia, all of which have seen some evidence of declines in the incidence of abortion-related illness and death.
Changes in abortion incidence between 1995 and 2008 coincide with a stall in the uptake of modern contraceptive methods. Other research has found a positive correlation between unmet need for contraception and abortion levels in developing countries. Family planning services seem not to be keeping up with the increasing demand driven by the increasingly prevalent desire for small families and for better control of the timing of births. The authors say*: "This plateau in the global abortion rate from 2003 to 2008 coincides with a U.N. documented slowdown in contraceptive uptake in the past decade, which has been especially marked in developing countries."
They conclude: "The substantial decline in the abortion rate observed earlier has stalled, and the proportion of all abortions that are unsafe has increased. Restrictive abortion laws are not associated with lower abortion rates. Measures to reduce the incidence of unintended pregnancy and unsafe abortion, including investments in family planning services and safe abortion care, are crucial steps toward achieving the Millennium Development Goals."
In a linked Comment, Dr Beverly Winikoff and Dr Wendy R Sheldon, Gynuity Health Projects, New York, USA, say: "Sedgh and colleagues' study shows that it is precisely where abortion is illegal that it must become safer. The public health community will not be able to address maternal mortality adequately and attainment of Millennium Development Goals is questionable until we directly confront the issue of unsafe abortion."
Dr Richard Horton, Editor of The Lancet, adds**: "These latest figures are deeply disturbing. The progress made in the 1990s is now in reverse. Promoting and implementing policies to reduce the number of abortions is now an urgent priority for all countries and for global health agencies, such as WHO. Condemning, stigmatising, and criminalising abortion are cruel and failed strategies. It's time for a public health approach that emphasises reducing harm—and that means more liberal abortion laws."
Note to editors: *quote direct from authors, not found in text of Article
**additional quote from Dr Richard Horton
For Dr Gilda Sedgh, Guttmacher Institute, New York, NY, USA (in London for media launch) please contact Cathy Bartley 44-7958-561-671 E) cathy.bartley@bartley-robbs.co.uk or Jessica Malter T) 646-315-2216 E) jmalter@guttmacher.org
For Guttmacher Institute contacts in the USA, please contact Rebecca Wind. T) 212-248-1111 ext. 2203 E) rwind@guttmacher.org
Dr Iqbal Shah, Department of Reproductive Health and Research, WHO, Geneva, Switzerland. T) 41-22-791-33-32 / 41-79-244-60-73 E) shahi@who.int
Dr Beverly Winikoff, Gynuity Health Projects, New York, USA. T) 212-448-1230 E) bwinikoff@gynuity.org
For Dr Richard Horton, please contact The Lancet Press Office. T) 44-20-7424-4949 E) tony.kirby@Lancet.com
Journal
The Lancet