Issues in Brief

THE ROLE OF CONTRACEPTION
IN REDUCING ABORTION

Following the 1994 election, which gave social conservatives a majority in the U.S. House of Representatives for the first time in 40 years, emboldened leaders of the antiabortion movement began to campaign openly against government-subsidized family planning programs. In a preview of the legislative assaults to come against both the international and domestic programs, House Pro-Life Caucus Chairman Christopher Smith (R-NJ) declared in January 1995 that he opposed U.S.-supported family planning efforts abroad because they lead to "abortion activism" and, by implication, result in more rather than fewer abortions.

The "evidence" for his claim derives in part from a misunderstanding of the data. Following the introduction of family planning programs, contraceptive use and abortion rates in some countries have initially risen simultaneously; in other countriesincluding the United Statescontraceptive use is nearly universal, but abortion rates have only recently begun to decline significantly. These data have been used to legitimate the assertion that the availability of contraception itself causes more abortions.

In the two and a half years since Smith's comment, the proponents of this view have sowed sufficient doubt among enough policymakers about the role of family planning programs domestically and internationally to disrupt a decades-long political consensus. Previously, all but a very small minority considered self-evident the view that better access to and more effective use of contraceptives are necessary to reduce the incidence of abortion.

Common sense still leads most people to the conclusion that more effective contraception means fewer abortionsand research results point to that conclusion as well. Individual women who use an effective method of contraception simply are much less likely to face an unintended pregnancy and the decision of whether to have an abortion than women who do not. Similarly, the advent of high-quality contraceptive services, both in the United States and elsewhere, has been shown over time to be associated with lower levels of abortion.

Fundamentally, the relationship between contraceptive use and abortion is explained by a single phenomenon: the inexorable and universal trend toward couples' wanting, and having, smaller families and trying to time the birth of their children to best advantage. Acknowledgment of this reality is important, since an individual's decision to practice contraception or to have an abortion stems from this same goal.

This Issues in Brief seeks to explain the statistical trends in the context of women's lives, their reproductive goals and the choices available to them. A great deal of information exists, largely from research in the United States, on the likelihood that an individual can avoid an unintended pregnancy, and abortion, by practicing effective contraception. Analyses of the effectiveness of contraceptive programs in reducing abortion rates come from the experiences of many countries, including the United States.

CONTRACEPTION WORKS FOR INDIVIDUALS
As more and more couples feel strongly about limiting the number of children they have, and about having those children when they want them, the demand for contraception will be great; in its absence or in the event of its failure, so will the demand for abortion. The choice for societies is whether to facilitate access to contraception or to leave women and their families with abortion, legal or not, as the only means of achieving their childbearing goals.

American women typically want two children, as do women in European countries and many parts of Asia. In Latin America, the average preference is for two or three children. Women in Sub-Saharan Africa still want large families, five or six children on average, but indications are that, as in more developed countries, their desired family size is beginning to decline, too. These numbers represent women's goals, but not necessarily their experience. In most countries of the world, a significant proportion of women reveal that they have actually had more children than they had intended.

To succeed in having the number of children she wants when she wants them, a woman must use contraceptive methods properly for a long time. The fewer the desired number of children, the longer the period of time. For example, if a woman marries or becomes sexually active at 20, remains sexually active through her reproductive years (roughly until age 45) and wants only two children, she must practice contraception for approximately 240 months, or 20 years (see Chart A).

Note: Distributions assume that women marry at age 20 and remain sexually active between ages 20 and 45. Source: Alan Guttmacher Institute, Hopes and Realities, New York, 1995, p. 39.

Data from the United States illustrate how contraception reduces abortion on a personal level. Virtually all American women who are sexually active but wish to avoid becoming pregnant use some form of birth control, since they have concluded that contraception is the most effective way to reduce the likelihood of a crisis pregnancy and the possibility of an unwanted birth or abortion. The facts support them: Women using a method of contraception are only 15% as likely as women using no method to have an abortion. In other words, contraception reduces the probability of having an abortion by 85%.

Yet, because of the enormous effort involved in practicing contraception continuously and effectively for more than two decades, almost half of all American women will have had at least one abortion by the time they are 45. It might seem contradictory to some and appear to be the "smoking gun" to others that the U.S. abortion rate (26 abortions per 1,000 women of reproductive age) is high by industrialized-country standards, even though 90% of women use a method. The explanation is that most of the unintended pregnancies and a disproportionate share of the resulting abortions occur among the 10% of women who use no method of birth control (such as teenagers having early sexual experiences) or use one only sporadically. The remaining abortions result among women trying to prevent an unwanted pregnancy whose contraceptive fails.

Some of the failure is due to the methods themselves, but most is a result of the difficulties that individual women confront in incorporating the task of contraceptive use into their everyday lives; over half of all women practicing contraception use a method that requires ongoing attention (as opposed to surgical sterilization). They include women who rely on oral contraceptives as well as those using intercourse-related methods such as the condom and the diaphragm. Practicing the prevention of pregnancy, therefore, is at least as difficult as other such preventive health strategies as maintaining a proper diet, exercising and quitting smoking. In this light, perhaps what is surprising is how many women manage to use birth control well.

REDUCING ABORTION RATES TAKES TIME
Individual countries have had very different histories in attempting to attain a balance between contraceptive use and reliance on abortion to control fertility. Some of the variation is associated with cultural and socioeconomic differences, but much of it relates to the disparity between actual and desired family size and the extent to which women were relying on abortion--regardless of its legal statusto limit childbearing before the introduction of family planning programs.

Russia's experience presents a stark and contemporary example of a situation where abortion has been legal for a long time, and because modern methods of contraception were unavailable for many years, abortion became the predominant method of controlling fertility for most women. According to the Russian Ministry of Health, the official abortion rate hovered around 109 abortions per 1,000 women of reproductive age in 1990, with only an estimated 19% of Russian women relying on modern contraceptives. By 1994, however, the health ministry reported that contraceptive use had risen to 24%, while the abortion rate had plummeted to 76 abortions per 1,000 women. Even taking into account the possibility of incomplete reporting, there is no doubt that the number of abortions is on the decline.

The desire of Russian women for small families is well established, intense and pervasive. Until now, a typical Russian woman who wanted only two children would have up to four abortions in her lifetime (although it would not be unusual for some women to have more). Even though the Russian abortion rate remains among the world's highest, Russian women are quickly seizing the opportunity they have been given to use modern birth control methods and are doing so relatively successfully.

Unlike Russia, both legal abortion and access to contraception have been available in Hungary, South Korea and the United States. Each country has had a different experience over time, but all have arrived at a point where abortion rates are on the decline.

Data from Hungary show the trend in contraceptive use and abortion over a 30-year period. In the late 1950s, most women were relying on abortion rather than contraception to limit the size of their families. Then, in the mid-1960s, an increase in the availability of contraceptives led to a sharp rise in their use, which continued through the mid-1980s. At almost the same time, the levels of abortion began to drop sharply (see Chart B).

Sources:S.K. Henshaw and E. Morrow, Induced Abortion: A World Review, 1990 Supplement, The Alan Guttmacher Institute, 1990; and United Nations, World Contraceptive Use, data diskettes, New York, 1992.

In South Korea, the transition took another route but had the same result. When the desire for small families became a cultural norm in the 1960s, both abortion and use of contraceptives initially rose together, creating a period of rapid fertility decline. In the decade between the late 1970s and the late 1980s, however, the abortion rate, which had peaked at 83 abortions per 1,000 women, declined to 54 per 1,000. Meanwhile, contraceptive use tripled, from 24% of married women of reproductive age to 77%.

The number of abortions has not yet dropped further, primarily because a sizable number of South Korean women who practice contraception still rely on some of the less effective methods. In the meantime, the motivation for smaller and smaller families has intensified, and increasingly through use of contraceptive methods, but also abortion, the average number of children per woman has fallen from six to less than two over a 20-year period.

The pattern in the United States is somewhat similar to South Korea's, although less dramatic. Here, the cultural norm of having a small family was well established by the 1960s. Contraceptive use was relatively high also, although so were contraceptive failures, unintended pregnancies, unplanned births and clandestine abortions. With the legalization of abortion nationwide in 1973, the abortion rate increased for a brief time as services became available; by 1980, however, the rate had peaked and then began a gradual decline. The rate has dropped more quickly since 1990, accompanied by an increase in the number of women using contraceptives, using them better and shifting to more effective methods.

In some countries, the provision of abortion remains illegal but the desire for smaller families is rapidly becoming stronger and more widespread, outpacing the availability of the means to achieve family-size goals. Research on the number of Latin American women who obtain clandestine abortions highlights the effect on the abortion rate of the relatively recent introduction of contraceptive services in that region.

By 1990, contraceptive use had risen dramatically throughout Colombia and Mexico, while abortion rates had essentially stabilized at their mid-1970s levels of about 34 and 23 abortions per 1,000 women, respectively. Abortion appears to have played a significant role in containing family size throughout the region, as Latin American women began to shift from having 67 children each to only 34. Abortion rates in many areas initially rose or were already fairly highdespite laws against the practice of abortionbecause contraceptive services were scarce. Although contraceptive use has risen, abortion rates are declining only gradually, partly because of the time it takes for contraceptive services to become widely accessible. Even more difficult is the development of the necessary cultural and behavioral shifts to successfully prevent unintended pregnancya goal that still remains elusive for many women in the United States.

A look at the major urban areas in Colombia and Mexico City clearly reflects the underlying trends. Between 1976 and 1990, the abortion rate in Bogotá fell by 40%, while contraceptive use doubled. During the same period, the abortion rate in Mexico City first climbed to a high of about 40 abortions per 1,000 women and then dropped to the mid-20s, while contraceptive use doubled (see Chart C). If the strong family planning programs in these cities can be replicated in small towns and rural areas, the national abortion levels, which have plateaued, are likely to show unmistakable signs of declining soon.

Source: S. Singh and G. Sedgh, "The Relationship of Abortion Trends to Contraception and Fertility in Brazil, Colombia and Mexico," International Family Planning Perspectives, 23:414, 1997, Figures 2 and 3.

ABORTION LAWS AND ABORTION RATES
The data clearly demonstrate the dampening effect of contraceptive use on abortion rates, even though it often takes time for the impact to be seen. Skeptics remain, however, largely among those whose main strategy for reducing abortion is to criminalize it. But while it may seem paradoxical, the legal status of abortion appears to have relatively little connection to its overall pervasiveness. In some parts of Latin America, for example, the abortion rate is as much as twice that of the United States. Worse, mainly because the procedure must be done clandestinely, it is associated with a high incidence of maternal death and disability. By contrast, in many countries where abortion is legal and performed under safe conditions, abortion rates are among the world's lowest (see Table 1).

The World Health Organization estimates that about 20 million clandestine abortions occur each year, the vast majority in South and Southeast Asia, Sub-Saharan Africa, and Latin America and the Caribbean. Any serious efforts to reduce either the overall number of abortions in these countries or the almost 600,000 maternal deaths each year--about 80,000 as a direct result of unsafe, illegally performed abortions--cannot succeed by making abortion there "more illegal."

If the main effect of abortion's legal status is on its safety, not its likelihood, then abortion rates of various countries must be explained by other factors. The two most important ones are the extent to which women are at risk of unwanted pregnancy (which depends largely on how many children they want and how strongly they feel about it) and the prevalence and effectiveness of contraceptive use. Abortion rates are believed to be low in some Islamic countries, for example, because couples there still want to have large families and because the consequences of sex outside marriage are very severe for women. At the opposite end of the legal and cultural spectrum, the abortion rate is low in the Netherlands, but for completely different reasons. Dutch women want very small families and high rates of premarital sexual activity prevail, but because of widespread reliance on effective contraception, abortion is uncommon.

A CRITICAL JUNCTURE
In much of the world, abortion rates have already declined or are beginning to do so. In most cases, the declines have been made possible by the increased availability, greater acceptance and more effective use of contraceptive services. Sub-Saharan Africa, with the world's fastest growing population, is at a crucial turning point. Although women there still want relatively large families, they too are increasingly expressing the desire to have fewer children than their mothers did. These beginnings of a desire for fewer children and a nascent shift from traditional family planning methods to more modern ones are driving a rising need for contraceptive services. In the absence of stronger contraceptive programs, however, African women may turn more frequently to abortion, even unsafe abortion, if it is the primary means available to limit their childbearing. To avoid this situation, better and more contraceptive services are essential.

Contraception, even under the best of circumstances, cannot end the need for abortion entirely. Contraceptive methods will never be perfect, and women and men will never be perfect users of them. What common sense and research show, however, is that the most effective means of reducing abortion is preventing unintended pregnancies in the first place. No serious effort to achieve this end, and thus reduce abortion, can succeed without contraception.

INFORMATION SOURCES
The Alan Guttmacher Institute (AGI), Preventing Pregnancy, Protecting Health: A New Look at Birth Control Choices in the United States, New York, 1991.

S.K. Henshaw, "Abortion Laws and Practice Worldwide," Choices, 26:26, 1997.

S.K. Henshaw and K. Kost, "Abortion Patients in 19941995: Characteristics and Contraceptive Use," Family Planning Perspectives, 28:140147 & 158, 1996.

S. Singh and G. Sedgh, "The Relationship of Abortion Trends to Contraception and Fertility in Brazil, Colombia and Mexico," International Family Planning Perspectives," 23:414, 1997.

S. Singh and M. Klitsch, "Are Women Achieving Their Childbearing Goals?" Issues in Brief, AGI, Nov. 1996.

U.S. Agency for International Development, The Role of Family Planning in Preventing Abortion, Washington, DC, 1996.

This report was written by Susan A. Cohen. It was prepared with the support of The Pew Charitable Trusts/Global Stewardship Initiative.

© copyright 1997, The Alan Guttmacher Institute.