Abortion in Context: United States and Worldwide

Abortion is one of the most divisive and emotional issues facing U.S. policymakers today. This should not be surprising, given that individuals' attitudes about abortion are shaped by their convictions regarding religion, morality, human rights, public health and the status of women in society. Moreover, lawmakers in the United States are not alone in their struggle over abortion policy. Abortion is controversial in many countries, and nations from every region of the globe are wrestling with questions about abortion, unintended pregnancy and the appropriate role of government in these matters.

Many of these policy debates are driven by the motivation to reduce abortion rates, and among some policymakers, the answer is to make abortion difficult to obtain or even illegal. Yet an examination of statistical trends reveals that the legal status of abortion in a country is not strongly correlated with the rate at which it occurs. Indeed, in many countries where the procedure is illegal, women obtain abortions at very high rates. Similarly, in some countries where abortion is legal and very widely accessible, abortion rates are low.

Clearly, factors other than legality are at play here. The primary factor is the rate at which women experience unintended pregnancies. Some women who have an unintended pregnancy will seek an abortion regardless of its legal status—even if they have to jeopardize their lives by undergoing an unsafe, illegal procedure. Thus, while there may be little relationship between abortion legality and abortion incidence, there is a strong correlation between abortion legality and abortion safety.

In 1999, The Alan Guttmacher Institute issued a major report, Sharing Responsibility: Women, Society and Abortion Worldwide, that brings together the latest research findings from approximately 60 nations about abortion law, the incidence of abortion and the conditions under which abortion occurs around the world. By discussing abortion in the context of unplanned pregnancy and placing the U.S. situation in a worldwide context, that report and this companion Issues in Brief strive to increase understanding of the role that abortion plays in women's lives. This information can improve policymakers' ability to ensure that women seeking to fulfill their childbearing goals—in the United States and around the world—are able not only to protect their lives and health should they decide to have an abortion, but to avoid unplanned pregnancies in the first place.

Unintended Pregnancies

Of the estimated 210 million pregnancies that occur annually around the world, nearly four in 10 are unplanned. In the most general terms, unplanned pregnancies occur when couples fail to reconcile their desire for sexual intercourse with their intention or reluctance to conceive a child at a particular time. However, reconciling these aspects of their lives requires couples to perform a complex balancing act, which may be influenced by their individual circumstances, features of their relationship and societal norms. And that balancing act becomes increasingly difficult when couples want small families.

Throughout this century, as modernization, urbanization and women's levels of education and participation in the labor force have grown, small families have increasingly become the norm worldwide. American women typically want two children, as do women in European countries and many parts of Asia. In Latin America, the average preference is between two and three children. Only in Sub-Saharan Africa do women still want relatively large families—five or six children, on average—but even there, desired family size has declined (from seven or eight children) since the 1970s.

Moreover, most couples want to control not only the size of their family, but the timing and spacing of their births as well. Accordingly, the vast majority of married women of childbearing age either have already achieved their desired family size or want to delay their next birth for at least two years. In almost all countries, at least six in 10 women—and in most countries, more than eight in 10—want to stop having children or to postpone their next birth.

Yet in many countries, women still have more children than they ideally would like. Large proportions of married women report that in the past five years, they had an unplanned birth—one that occurred either sooner than they had wished (a mistimed birth) or at a time when they had wanted no more children ever (an unwanted birth). The proportion of women who describe a recent birth as unplanned is striking everywhere, but it is particularly high in Kenya, the Philippines, Latin American countries and Japan (Chart A).

Contraceptive use is critical to couples' ability to reconcile their sexual lives and their childbearing goals. However, effective contraceptive use presents significant challenges for women and men all over the world. If a couple wants to have between two and four children, they must practice birth control successfully for 16-20 years. Yet women in many developing countries do not have access to the contraceptive supplies or family planning services they need, because contraceptives are too expensive, supplies are erratic, services are difficult or impossible to obtain, or the quality of care is poor.

Whether couples are successful in preventing unplanned pregnancies depends not only on their having reliable access to family planning services but also on how effectively they practice contraception. However, all contraceptive methods have drawbacks. Some have inherently high failure rates, while others are difficult for women (or their partners) to use on a consistent basis.

For example, many women find it difficult to take the pill every day, year after year, or to consistently use intercourse-related methods, such as the condom or diaphragm. Some women fear having an IUD inserted, feel powerless to insist on condom use or cannot tolerate the side effects they experience when using hormonal methods (the pill, injectable or implant). Traditional methods, such as periodic abstinence and withdrawal, are still popular in many countries, but they are not easy to use and have high failure rates. Contraceptive sterilization, in contrast, is extremely effective, but is permanent and therefore not appropriate for people unsure about future childbearing.

For many couples, effective contraceptive use is complicated by cultural, religious and social factors that affect women's ability to participate fully in reproductive decision-making. Women's educational attainment, participation in the labor force, age at marriage, role within the family and society, and likelihood of being subjected to domestic violence are critical determinants of their ability to control whether and when to have children. In many countries, barriers to women's participation in reproductive decision-making reflect women's second-class position within the family and their neglected status within the larger society.

Abortion Laws and Rates

Each year, more than half of unintended pregnancies worldwide—46 million, or two in 10 total pregnancies—are resolved by induced abortion. Throughout the world, women give similar reasons for deciding to have an abortion: They are too young or too poor to raise a child; they are estranged from or on uneasy terms with their sexual partner; they are unemployed; they do not want a child while in school; or they want or need to work. That women's reasons for choosing abortion are similar around the world highlights the common experiences women face when trying to juggle competing roles and responsibilities while adapting to changing social expectations.

Indeed, women have relied on abortion to end unwanted pregnancies throughout history and in every region of the world, even though abortion was illegal in almost every country until the second half of this century. By the mid-1980s, most developed countries and several developing countries had lifted these prohibitions, but the legal status of abortion remains highly variable.

Currently, six in 10 women—55% of those in the developing world and 86% in the developed world—live in countries where abortion is permitted on broad grounds (Chart B). In these countries, the law allows abortion when it is necessary to protect a woman's life or her physical or mental health, for socioeconomic reasons or without regard as to reason, at least during the early months of pregnancy. (Even where abortion is broadly permitted, however, the law typically stipulate conditions, such as gestational limits or consent requirements.) By contrast, 25% of women live in countries, overwhelmingly in the developing world, where abortion is prohibited altogether or allowed only to save a woman's life.

Although women in developing countries are much more likely than women in developed countries to live under restrictive abortion laws, levels of abortion are about the same for both groups (Chart C). In any given year, 34 abortions occur per 1,000 women in the developing world, and 39 are performed per 1,000 women in developed countries. However, abortion rates vary considerably among countries, ranging from fewer than 10 to more than 80 abortions per 1,000 women (Chart D).

Yet, while it may seem paradoxical, a country's abortion rate is not closely correlated with whether abortion is legal there. For example, abortion levels are quite high in Latin American countries, where abortion is highly restricted. (In fact, 20 million of the 46 million abortions performed annually worldwide occur in countries with highly restrictive abortion laws.) At the same time, abortion rates are quite low throughout Western Europe, where the procedure is legal and widely available. Also, Eastern and Western Europe have the world's highest and lowest abortion rates, respectively, yet abortion is generally legal throughout the Continent.

If legality is not the determining factor, what drives the rates at which abortions occur in a given country? Clearly, a key factor is the rate at which women experience unintended pregnancies—itself a function of the interplay between a couple's family-size (and timing) goals and their contraceptive use.

Abortion levels are high in countries where the desire for small families is strong but contraceptive use is low or ineffective. For example, in most of Eastern Europe and the former Soviet republics, where desired family size has been small for many years, modern contraceptive methods were not generally available until recently. As a result, women relied on abortion—which was legal, safe and easily accessible—to regulate births. However, as contraceptives have become much easier to obtain in recent years, the situation has begun to change rapidly, and abortion rates in some of these countries fell by as much as 50% between 1990 and 1996.

In sharp contrast, even in countries where abortion is legal and widely available, abortion rates are low if couples practice contraception effectively to limit or space births. In the Netherlands, for example, where abortion has been legal and widely accessible for many years, abortion and unintended pregnancy rates are low because of widespread contraceptive use.

Legality and Safety

When abortion occurs under legal conditions, it is usually performed early in pregnancy by a skilled practitioner using an accepted medical or surgical method in a hygienic setting; in such circumstances, the risk of complications and maternal morbidity is low. However, when abortion is largely illegal and must be performed clandestinely, it often is unsafe; in such situations, complication rates and maternal morbidity skyrocket.

The death rate associated with abortion is hundreds of times higher in developing regions, where the procedure is often illegal, than in developed countries (Table 1). The rate is highest—almost 700 deaths per 100,000 procedures—in Africa. Since well-off women in cities are frequently able to obtain safe abortions even when it is against the law, the majority of deaths and complications from abortion occur among low-income women and women living in rural areas who undergo unsafe, illicit procedures.

Table 1 Abortion-Related Deaths
Region	Deaths per 100,000 abortions
Developing1	330
Africa	680
South & Southeast Asia	283
Latin America	119
Developed	.0.2-1.2
1. Excluding China. Source: The Alan Guttmacher Institute (AGI), Sharing Responsibility: Women, Society and Abortion Worldwide, New York: AGI, 1999, p. 35.

The World Health Organization estimates that of the approximately 600,000 pregnancy-related deaths each year, 78,000 are related to complications resulting from unsafe abortion. In Latin America, as many as 21% of maternal deaths are estimated to be associated with unsafe abortion. Many women experiencing complications from unsafe abortion, particularly those who live in rural areas, do not have access to appropriate medical treatment. Others do not seek treatment because of fear, embarrassment, shame or poverty.

By legalizing abortion, countries can help reduce or eliminate the need for unsafe abortion. This, in turn, will significantly lessen the number of deaths related to abortion, reduce the likelihood of complications and improve women's subsequent health. For example, when Romania legalized abortion in 1990, its abortion-related mortality rate fell to one-third of its peak level—reached only one year before—of 142 deaths for every 100,000 live births.

Legalizing abortion, however, does not by itself guarantee safety. For example, in India, where abortion has been legal on broad grounds for almost 30 years, many women, especially in rural areas, do not even know that abortion is legal. Authorized facilities that provide safe abortions services are inadequate in number, and some women have found their treatment by government health professionals to be degrading. As a result, women frequently go outside the authorized system and obtain extralegal abortions, many of which are unsafe.

By the same token, illegal abortions are not necessarily unsafe. In some Latin American countries, abortion is sufficiently openly available and tolerated, especially in metropolitan areas, to be quite safe—at least for women who can afford to have a skilled provider perform the procedure.

Even in countries where abortion is legal under broad circumstances, the law may impose restrictions that impair a woman's ability to obtain a safe and timely abortion, increasing the chance of adverse health consequences. For example, the need for permission from a husband or parent, mandatory counseling requirements and waiting periods, or the need to locate or travel to an authorized provider may mean that abortions are performed later in a pregnancy than they otherwise would be.

Women may also delay having an abortion if they live in a country with a restrictive law and need to travel to a country where the procedure is legal. That is part of the reason, for example, why nonresidents who travel to England for an abortion are far more likely than British women to undergo the procedure in the second trimester.

In addition to the procedure's legal status, costs associated with abortion can affect safety and health outcomes for women. In countries where the cost of an abortion is high relative to family income and where the procedure is neither covered under private health insurance systems nor publicly financed, a woman may delay obtaining an abortion until she has raised the funds necessary to pay for the procedure. Alternatively, she may be forced to obtain an illegal—and potentially unsafe—abortion from a provider who charges less than an authorized provider.

The U.S. Picture

As do most women around the world, American women typically want—and have—small families. Most women in the United States, whatever their race and ethnicity, have two children; the exception is that Hispanic women, many of whom are recent immigrants, typically have three.

But while couples in this country ultimately are successful in achieving their desired family size, they experience considerable difficulty in doing so. American women's high rates of unintended pregnancy testify to the problems they face in practicing contraception consistently throughout their reproductive lives. Half of the six million pregnancies that occur in the United States each year are unintended. About half of unintended pregnancies occur among the 10% of women at risk of an unintended pregnancy who do not use birth control (particularly teenagers and older married women) or who use a method only sporadically. The rest occur among women who practice contraception to prevent an unwanted pregnancy.

Given American women's relatively high rates of unplanned pregnancy, it should not be surprising that their abortion rate—23 per 1,000 women of reproductive age—is undeniably high by the standards of developed nations. (It is, however, considerably lower than rates in developing countries.)

Some abortion opponents allege that the U.S. abortion rate is due to the extreme "permissiveness" of the nation's abortion policy. (As the result of the Supreme Court's 1973 decision in Roe v. Wade, the right to choose abortion is constitutionally protected until fetal viability, after which states may prohibit abortion except when it is necessary to save a woman's life or protect her health.) In practice, however, U.S. policy is roughly comparable to that of many Western European countries (which, moreover, pay for the procedure under their national health programs)—and virtually all of these countries have much lower abortion rates. Consistent with the experience of other countries around the world, the key variable that accounts for the high U.S. abortion rate is not a permissive law but a high unintended pregnancy rate.

At the same time, and also consistent with the worldwide picture, abortion is extremely safe in this country—far safer than it was prior to Roe v. Wade, when the procedure was illegal in many states. Before Roe, women's choices, and experiences, were similar to those of women in developing countries today. Less affluent women who could not afford to travel to states where abortion was legal commonly turned to illegal, clandestine procedures—which often resulted in serious health complications and sometimes death. Even some better-off women who could afford to travel suffered consequences associated with delaying their abortions. And complications of abortion were a major cause of hospital admission.

But as has been the experience in other countries, legalization has enabled women to obtain earlier, safer abortions. Today, more than half of abortions in this country occur within the first eight weeks of gestation, three-quarters within 12 weeks and almost 99% within 20 weeks. (A full-term pregnancy lasts 38 weeks.) A woman's risk of dying from abortion-related complications in this country (0.4 deaths per 100,000 procedures performed before eight weeks' gestation) is significantly lower than her risk of dying as the result of pregnancy or childbirth (seven deaths per 100,000 live births).

Policy Implications

Ultimately, women the world over seek abortions for the same reason: because they have an unintended pregnancy. How such a pregnancy is resolved has been, and always will be, an individual decision, despite the law. But ensuring that whatever decision a woman makes will not harm her health and providing her the means to reduce the likelihood of experiencing an unplanned pregnancy in the first place are key challenges facing policymakers.

In this regard, understanding that the legal status of abortion correlates much more with its safety than with its incidence is critical. One need only look at the experience in many developing countries—with their high rates of maternal death and disability related to illegal, unsafe abortions—for a powerful reminder of the social and medical costs routinely borne by women when access to safe abortion is denied.

Moreover, efforts focusing on restricting access to abortion in order to reduce its incidence are misguided; public policy should concentrate on helping women prevent unplanned pregnancies. Therefore, key policy objectives must include improving women's access to comprehensive family planning services and promoting the effective use of contraceptives.

Notably, abortion rates are declining in the United States, and have reached their lowest point in 20 years, largely because rates of unintended pregnancy have declined as the result of improved contraceptive use (particularly among teenagers). Yet many women in this country still lack access to affordable contraceptives. In stark contrast to women in developed countries that have universal health insurance, many American women do not have either public or private insurance coverage for contraceptives and cannot afford the high up-front costs associated with many forms of contraception, including the long-lasting and most effective reversible methods.

Policies seeking to capitalize on recent progress in reducing unintended pregnancy and abortion rates should improve coverage of contraceptive services under private insurance; expand contraceptive access under Medicaid, the health insurance program for the poor; and preserve the viability of the national family planning clinic system, supported largely by the federal Title X program, which serves as a safety net for uninsured, low-income women and teenagers.

Finally, as a leader in world affairs, this country has an obligation to reduce unintended pregnancy and abortion that reaches beyond its borders. The need for effective contraceptive services is growing in many regions of the world, and women may increasingly turn to abortion—even unsafe abortion—should this need continue to go unmet. Support for U.S. population assistance will help to meet the demand for contraceptives while improving the health of women and children around the globe and reducing the need for abortion.

Unfortunately, contraceptive availability will never make unplanned pregnancies, and the abortions that inevitably follow them, disappear completely. Contraceptives are not perfect, nor are the people who use them. Ultimately, improved access to effective methods of contraception is a necessary part of any serious effort to reduce unintended pregnancy and abortion—at home or abroad.

Sources of Data

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