induced abortion: incidence and trends worldwide from 1995 to 2008

8/3/2019 Induced abortion: incidence and trends worldwide from 1995 to 2008

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AbstractBackgroundDataofabortionincidenceandtrendsareneededtomonitorprogresstoward

improvementofmaternalhealthandaccesstofamilyplanning.Todate,estimatesofsafeandunsafeabortionworldwidehaveonlybeenmadefor1995and2003.

Methods

WeusedthestandardWHOdefinitionofunsafeabortions.Safeabortionestimateswerebasedlargelyonofficialstatisticsandnationallyrepresentativesurveys.Unsafeabortionestimateswerebasedprimarilyoninformationfrompublishedstudies,hospitalrecords,andsurveysofwomen.Weusedadditional

sourcesandsystematicapproachestomakecorrectionsandprojectionsasneededwheredataweremisreported,incomplete,orfromearlieryears.Weassessedtrendsinabortionincidenceusingratesdevelopedfor1995,2003,and2008withthesamemethodology.Weusedlinearregressionmodelstoexploretheassociationofthelegalstatusofabortionwiththeabortionrateacrosssubregionsoftheworldin2008.

Findings

Theglobalabortionratewasstablebetween2003and2008,withratesof29and

28abortionsper1000womenaged1544years,respectively,followingaperiodofdeclinefrom35abortionsper1000womenin1995.Theaverageannualpercentchangeintheratewasnearly2.4%between1995and2003and0.3%between2003and2008.Worldwide,49%ofabortionswereunsafein2008,comparedto44%in1995.Aboutoneinfivepregnanciesendedinabortionin2008.Theabortionrateislowerinsubregionswheremorewomenliveunderliberalabortionlaws(p


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IntroductionInformationonglobalandregionalabortionratesandtrendscanhelpidentifygapsincontraceptiveuse.Althoughabortionsdoneaccordingtomedicalguidelinescarryverylowriskofcomplications,[13]unsafeabortionscontribute

substantiallytomaternalmorbidityanddeathworldwide.[46]Monitoringabortiontrendsisthuscrucialtoassessimprovementofmaternalhealth,andtheprogresstowardtheUNMillenniumDevelopmentGoal5(MDG5),toreducematernalmortalityandachieveuniversalaccesstoreproductivehealth.

Moreover,oneofthemanycontroversiessurroundingabortioniswhetherrestrictiveabortionlawspreventwomenfromobtainingabortions.Analysesoftheassociationbetweenabortionincidenceandthelegalstatusofabortioncanclarifywhetherlawisafactorthataffectsabortionincidence.

However,abortionsarenotdocumentedincountrieswithhighlyrestrictiveabortionlawsandareoftenunderreportedelsewhere,especiallywherethepracticeishighlystigmatized.Therefore,estimationofregionalandglobalincidencerequirescompilationofinformationfromarangeofsourcesandcarefulassessmentofinformationforqualityandcompleteness.Variousdatasourcesandestimationapproacheshavebeenassessed,refined,andappliedovertheyears,andarenowwidelyacceptedassourcesofreasonablenationalestimates.[4,79]

Weestimatedtheincidenceofsafeandunsafeabortiongloballyandinallthe

majorregionsandsubregionsoftheworldin2008.Weassessedtrendssince

1995and2003,theonlyotheryearsforwhichsimilarassessmentsweredone.

Wealsoexaminetheassociationsofabortionincidencewiththelegalstatusof

abortionacrosstheworldssubregions.

Methods

DefinitionsanddatasourcesWeadheredtothedefinitionofunsafeabortionestablishedbyWHO,namely,a

procedureforterminationofanunintendedpregnancydoneeitherbypeople

lackingthenecessaryskillsorinanenvironmentthatdoesnotconformto

minimummedicalstandards,orboth.[10]AselaboratedbyWHO,[4,11]

abortionsdoneoutsidetheboundsoflawarelikelytobeunsafeeveniftheyare


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donebypeoplewithmedicaltrainingforseveralreasons:suchproceduresare

usuallydoneoutsidefacilitiesauthorizedtoperformabortions,sometimesin

unsanitaryconditions;thewomanmightnotreceiveappropriatepostabortion

care;medicalbackupisunlikelytobeimmediatelyavailableshouldan

emergencyarise;andthewomanmightdelayseekinganabortionorseekingcare

forcomplicationsbecausetheabortionisclandestine.Thus,asinpreviousefforts

toestimateabortionincidenceandconsistentwithWHOpractice,weusedthe

operationaldefinitionofunsafeabortions,whichisabortionsdoneincountries

withhighlyrestrictiveabortionlaws,andthosethatdonotmeetlegal

requirementsincountrieswithlessrestrictivelaws.Safeabortionsweredefined

asthosethatmeetlegalrequirementsincountrieswithliberallaws,orwherethe

lawsareliberallyinterpretedsuchthatsafeabortionsaregenerallyavailable.

Countrieswithliberallawsweredefinedasthosewhereabortionislegalon

requestoronsocioeconomicgrounds,eitherwithorwithoutgestationallimits;

andcountrieswhoselawsallowforabortiontopreservethephysicalormental

healthofthewoman,iftheselawswereliberallyinterpreted,asof2008.Tothe

bestofourknowledge,HongKongSpecialAdministrativeRegion,Israel,New

Zealand,SouthKorea,Spain,andEthiopiametthelattersetofcriteria.The

classificationofcountriesaccordingtowhethertheirabortionlawsareliberalor

restrictive

is

reviewed

elsewhere.

[12]

Although

the

legal

status

of

abortion

and

riskassociatedwiththeprocedurearenotperfectlycorrelated,itiswell

documentedthatmorbidityandmortalityresultingfromabortiontendtobehigh

incountriesandregionscharacterizedbyrestrictiveabortionlaws,[46]andis

verylowwhentheseareliberal.[13]

Weusedempiricalevidenceofsafeabortionsdoneoutsidetheboundsofthelaw

andunsafeabortionsdonedespiteliberallawswhenthisinformationwas

available.InIndia,abortionislegallypermittedandavailableunderbroad

conditions,butmanyabortionsneverthelesstakeplaceoutsideofhealthservices

legallyauthorizedtodoabortions;someofthesearedeemedsafeandsome

unsafe.[13]InCambodia,abortionislegaluponrequestthroughthefirst

trimesterofpregnancy,buthalfofallabortionsneverthelesstakeplacein

womenshomesandothersettingsoutsideofformalfacilities;[14]wedeemed


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suchabortionstobeunsafe.InsubSaharanAfrica,abortionlawisliberalin

ZambiaandSouthAfrica,andabortionislegalifitistopreservethehealthofthe

womaninsevenothercountries.WiththeexceptionofSouthAfrica,however,

theselawsarelargelynotimplemented,andmostabortionsinthesecountries

occurunderunsafeconditions. SomeabortionsinSouthAfricaarealsostillunsafe,

despitethemorewidespreadprovisionofsafeabortionservicessincethe

liberalizationofabortionlawin1996.[15]Smallpercentagesofabortionsarealso

knowntobeunsafeinsomeeasternEuropeanandothercountrieswithliberal

lawsthatwereformerlypartoftheSovietUnion.[16]Thereisevidencethat

somewomenrelyonunsafeabortionsintheUSAdespitetheliberalabortionlaw,

[17,18]andthesameisprobablytrueforotherdevelopedcountrieswithliberal

laws,butthesenumbersarenegligiblewheretheyhavebeenestimated.

Fortheglobalestimationofbothsafeandunsafeabortions,wegatheredrelevant

informationonabortionincidenceineverycountryandterritory,assessedthe

qualityoftheinformation,andmadesomeadjustmentstoaccountfor

misreportingandunderreporting,usuallyonthebasisofindicatorsrelatedto

abortionincidenceandqualityofreporting,frompublishedstudiesandreports.

Wecomputedsubregionalandregionalestimatesasthesumoftheestimatesfor

allcountriesinthesegeographicalareas.

Safeabortions57ofthe84countriesandterritorieswithliberalabortionlawshaveamechanism

forcollectionofstatisticsaboutproceduresdone.Statisticsfor2008were

obtainedmainlyfrompublishedandunpublishedreports,websitesofofficial

nationalreportingagencies,andquestionnairesgiventosuchagenciesbythe

studyteam.

Weassessedthequalityofofficialreportsusingfeedbackfromagencies

implicatedindatacollectionandfromexpertswhowerefamiliarwithreportingof

abortioninthecountries,includingdemographersandsocialscientists,and

programmanagers,providers,andpolicyadvisersfamiliarwithproceduresof

reportingofabortionsineachcountry.Issuesthataffectabortionreportingand


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assessmentsofthequalityofreportsfromspecificcountrieshavebeen

comprehensivelyreviewedelsewhere,[7,19]andtheseresourcesalsoservedas

theevidencebaseforadjustmentstothenationalfigures.Whereexpertsdeemed

thatstatisticsincludedatleast95%ofallabortionprocedures,asinseveral

northernandwesternEuropeancountries,noadjustmentsweremadetothese

reports.Forcountrieswithincompletestatistics,weusedthesamecorrection

factorusedtoestimateincidencein2003,whenwedidnothavesufficient

evidenceofachangeincompletenessofreporting.Thecorrectionfactorsapplied

toofficialstatisticsrangedfrom1.05to2.54(indicatingthatthereported

numberswereincreasedby5154%),andtheaverageofthecorrectionfactors

was1.26.

Forsixcountrieswithliberallaws,abortionestimateswereonlyavailablefrom

nationallyrepresentativesurveysofwomendonewithin5yearsoftheyearof

estimation.Therateofunderreportingfromsuchsurveysrangedfrom15%to

69%accordingtostudiesthatwereabletovalidatetheirfindings.[9,20,21]With

nosuchstudiesvalidatingfindingsforthesesixspecificcountries,weadjusted

surveyestimatesupwardby20%toaccountfortheminimumexpecteddegreeof

underreporting.Forseveralcountries,bothsurveybasedestimatesand

incompleteofficialreportswereavailable.Weprojectedadjustedsurveybased

estimatesforyearsearlierthan2008to2008usingtrenddatafromofficial

reports.Whennoevidenceofachangeintheabortionrateovertimewas

available,eitherfromofficialreportsorothersources,weappliedto2008the

ratefortheyearnearestto2008.

For13countriesandminorterritorieshavingnoabortionstatisticsorestimates,

including2%ofthefemalepopulationincountrieswithpredominantlysafe

abortion,weappliedalowvariant(10abortionsper1000women),medium

variant(20abortionsper1000women),orhighvariantabortionrate(50

abortionsper1000women),basedontheircontraceptiveprevalenceandfertility

rates,andinferencesdrawnfrominformationofabortioninsimilarsettings.


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UnsafeabortionsThecompilationofstudiesanddataonunsafeabortionisanongoingactivityof

WHOs

Special

Program

in

Human

Reproduction.

To

estimate

abortion

incidence,

wegatheredinformationfrompublishedandunpublishedsourcesobtainedfrom

websitesofnationalauthoritiesandnongovernmentalorganizations,data

reportedtoWHOHeadquartersandRegionalOffices,searchesoflibrary

databases,andthroughpersonalcontactswithresearchersworldwide.Wegave

preferencetonationalestimatespublishedinpeerreviewedjournalsorother

reportsusingwidelyacceptedmethodologies;whenthesereportswereabsent,

weprioritizednationallyrepresentativedata,mainlyhospitalizationrecords.In

theabsenceofnationaldata,weadjustedinformationfromsubnationalstudies

asneededtoprovidenationalestimatesbasedoneachstudysselectioncriteria.

Weappliedestimatesforyearsotherthan2008to2008whentherewasno

evidencetosuggestchangesinabortionlevels.Morenationalleveldatawere

availabletoinformtheestimatesfor2008thanfor1995or2003,especiallyfor

westernAsia,middleAfrica,andcentralAmerica,allowingformoreaccurate

estimatesforthosesubregionsin2008.

For

countries

with

available

data

on

numbers

of

women

admitted

to

hospital

for

complicationsfrominducedandspontaneousabortions,wecomputedunsafe

abortionincidenceusingawidelyusedtechniquethatentails(1)subtractionof

thelikelynumberofspontaneousabortioncases,and(2)applicationofan

adjustmentfactortoaccountfortheestimatednumberofwomenhaving

abortionswhodonotneedordonotreceivetreatment.Forseveralcountries,

publishedadjustmentfactorsderivedfromsurveysofknowledgeable

professionalsareavailable.[22]Forothers,thefactorwasassumedtobethe

sameasthatinacountrywithasimilarabortionlawandhealthcare

infrastructureandaknownadjustmentfactor.

Asalreadynoted,surveysofwomengenerallyunderestimateabortionincidence

becausealargeproportionofwomendonotreporttheirabortions.Under

reportingisevengreaterincountrieswithrestrictivelawsthanincountrieswith


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liberallaws.Studiesindicatethatatmosthalfofwomenincountrieswith

restrictiveabortionlawsreporttheirabortions,andweusedthisminimum

adjustmentforsurveybasedestimates.

For

11

countries

representing

5%

of

women

of

reproductive

age

living

where

abortionsareunsafe,weadjusteddatafromsubnationalstudiestoyieldnational

estimatesbyweightingtheresultstomatchtheruralandurbancompositionof

thecountry.Afewsmallcountriesforwhichnoinformationwasavailablewere

assumedtohavethesameabortionrateasothercountriesintheregionwith

similarabortionlaws,fertilityandcontraceptiveuse,ortheaveragerateofother

countriesintheregiontowhichtheybelong.

CertaintyofestimatesBecausefewoftheabortionestimateswerebasedonstudiesofrandomsamples

ofwomen,andbecausewedidnotuseamodelbasedapproachtoestimate

abortionincidence,itwasnotpossibletocomputeconfidenceintervalsbasedon

standarderrorsaroundtheestimates.Drawingontheinformationavailableon

theaccuracyandprecisionofabortionestimatesthatwereusedtodevelopthe

subregional,regional,andworldwiderates,wecomputedintervalsofcertainty

aroundtheserates(Availableonrequestfromauthors).Wecomputedwider

intervals

for

unsafe

abortion

rates

than

for

safe

abortion

rates.

The

basis

for

these

intervalsincludedpublishedandunpublishedassessmentsofabortionreporting

incountrieswithliberallaws,[7,19]recentlypublishedstudiesofnationalunsafe

abortion,[2325]andhighandlowestimatesofthenumbersofunsafeabortion

developedbyWHO.[4]Thebodyofcountryspecificevidenceonabortionhas

increasedwithtime,andmorerecentregionalandsubregionalestimateswere

thereforelikelytobemoreprecisethanolderestimates.

StatisticalanalysisWecalculatedabortionrates(numbersofabortionsforevery1000womenaged

1544years)usingUNPopulationDivision(UNPD)populationestimates.[26]We


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estimatedthenumberofpregnanciesasthesumoflivebirths(alsobasedon

UNPDestimates),abortions,andspontaneouspregnancylosses(miscarriagesand

stillbirths).Usingamodelbasedapproachderivedfromclinicalstudies,we

estimatedthatspontaneouspregnancylossesequaled20%ofallbirthsplus10%

ofallabortions.[27,28]RegionsweredefinedastheyarebytheUNPopulation

Division.[26]

Weexaminedtheassociationsoftheabortionratesintheworlds18subregions

withaccesstolegalabortion,measuredasthepercentofthefemalepopulation

aged1544yearslivingincountriesorterritorieswithliberalabortionlawsin

2008.Wedidunivariatelinearregressionanalysesafterensuringthatthe

assumptionsoflinearregressionmodelsweremet.WeusedSPSSversion18to

dothestatisticalanalyses.

RoleofthefundingsourceThesponsorsofthestudyhadnoroleinstudydesign,datacollection,data

analysis,datainterpretation,orwritingofthereport.Thecorrespondingauthor

hadfullaccesstoallthedatainthestudyandhadfinalresponsibilityforthe

decisiontosubmitforpublication.

ResultsAnestimated43.8millionabortionsoccurredin2008,comparedwith41.6million

in2003,and45.6in1995(table1).About78%ofallabortionstookplaceinthe

developingworldin1995,andincreasedto86%in2008,whereastheproportion

ofallwomenofreproductiveagewholiveinthedevelopingworldrosefrom80%

to84%inthesameinterval.Since2003,thenumberofabortionsfellby0.6

millioninthedevelopedworld,butincreasedby2.8millionindeveloping

countries.TheestimatedannualnumberofabortionsrosemoderatelyinAfrica

and

Asia,

and

slightly

in

the

Latin

America

region;

it

fell

slightly

in

Europe

and

NorthAmericaandheldsteadyinOceania(table1).

Althoughabsolutenumbersofabortionsmightincreaseasaresultofpopulation

growth,theabortionrateper1000womenisnotaffectedbythisfactor.Some28

abortionsoccurredforevery1000womenaged1544yearsin2008,compared


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with29in2003(table2).Takingintoaccountthecertaintyintervalsaroundthese

numbers,thisdifferencewasnotdeemedmeaningful.Thisinsubstantialchangein

theratefollowsaperiodofnotabledeclinefrom35abortionsper1000womenin

1995,representinganaverageannualdeclineofalmost2.4%between1995and

2003,comparedwith0.3%between2003and2008.

In2008,theestimatedratewas24inthedevelopedworldand29inthe

developingworld.Abortionrateshavebeenfairlystableattheregionallevelsince

2003,followingsmalldeclinesinsomeregions,mostnotablyEurope,between

1995and2003(figure1).

TheabortionratesintheAfricansubregionsrangedfrom15(southernAfrica)to

38(easternAfrica)in2008(table2).Thefluctuationintheratesformiddleand

southernAfricasince1995reflectsdifferencesinthequalityofdataavailableover

time;thelowerrateinsouthernAfricain2008alsoprobablyreflectsinparta

decreaseinabortionincidence.

AbortionratesacrosstheAsiansubregionsrangedfrom26(southcentraland

westernAsia)to36(southeasternAsia)in2008(table2).Thehighratein

southeasternAsiaispartlyduetothehighincidenceinVietnam,whichcomprises

15%ofthepopulationinthissubregion.Theestimatedabortionratesheldsteady

intheAsiansubregionsbetween2003and2008(table2).

In2008,thelowestsubregionalrateworldwidewasinwesternEurope(12)and

thehighestwasineasternEurope(43;table2).TheratesintheEuropean

subregionswereunchangedsince2003.ThesteadyratesinEasternandSouthern

Europefollowsharpdropsintheratebetween1995and2003.Theabortionrate

declinedmodestlyinOceaniabetween1995and2008.

Worldwide,49%ofabortionswereunsafein2008,upfrom44%in1995(table2).

Nearlyall(97%)abortionswereunsafeinAfricain2008(table2).Theproportions

ofabortionsthatareunsafevarywidelyacrossAsia,fromanegligibleproportion

ineasternAsiato65%insouthcentralAsia(table2).Theestimatedproportionof

abortionsthatareunsafeincreasedmostinwesternAsia,partlyasaresultof

declinesintheincidenceofsafeabortion.Some91%ofabortionsinEuropeare


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safe(table2).PracticallyalltheunsafeabortionsinEuropetakeplaceineastern

Europe,where13%ofabortionswereunsafein2008.

Theestimatedworldwideproportionofpregnanciesthatendinabortionwas21%

in

2008,

20%

in

2003,

and

22%

in

1995

(table

3).

In

the

developed

world,

abortion

declinedasapercentofallpregnanciesfrom36%in1995,to26%in2008.Itheld

steadyat1920%ofpregnanciesinthedevelopingworld(table3).The

proportionofpregnanciesthatendinabortionwaslowerindevelopingregions

thanindevelopedregions,partlybecausebirthrateswerehigherindeveloping

regions.Thesharpdeclineintheproportionofpregnanciesthatendedin

abortioninthedevelopedworldsince1995wasconcentratedineasternEurope

(datanotshown).ThisproportionalsodeclinedmodestlyinNorthAmericaand

Oceania.

In2008,theabortionratewaslowerinsubregionswherelargerproportionsof

thefemalepopulationlivedunderliberallawsthaninsubregionswhere

restrictiveabortionlawsprevailed(bcoefficientfortheassociationbasedona

linearregressionmodel0.11,p


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Evidencefromvariouscountries,includingsomewithhighlyrestrictiveabortion

laws,suggeststhattheuseofmisoprostolasanabortifacienthasbeenspreading.

[24,2931]Althoughclandestinemedicalabortionsarelikelytobeoflowerrisk

thanotherclandestineabortions,thereissubstantialvariationinmedical

abortionregimensusedillegally,andcomplicationssuchasprolongedandheavy

bleedingandincompleteabortionsareassociatedwithuseofincorrectdosages.

[30]Thus,theseproceduresareonthewholeclassifiedasunsafe.

Thesafetyofanabortionprocedureisalsoaffectedbythegestationalageatthe

timeoftheabortion.Womenmightdelayseekinganabortionwhereabortion

lawsarerestrictiveorabortioniswidelystigmatized,andtheprevalenceoflate

abortionsmightchangewithtime.[32]Researchongestationalageatabortionis

extremelyscarceandthisrepresentsagapinresearchonunsafeabortion.

Statisticsonabortionincidencearepronetomisreportingformanyreasons,as

elaboratedinreviewsofabortionestimationmethodologies.[8,9]Thesepotential

sourcesoferrorincludeomissionofprivatesectorabortions;inclusionof

spontaneousabortionsinsomeofficialreports;undercountingofmedical

abortions;underreportingofinducedabortionsinsurveysofwomen,and

misclassificationofabortionrelatedcomplicationsinhospitalizationrecords.We

used

various

sources,

including

published

studies,

models

based

on

biological

data,andinputfromkeyinformants,toassessthemagnitudeofthesebiasesand

tocorrectforthem.Weexpectthattherangeofrandomerrorincountryspecific

estimatesnarrowswhentheseareaggregatedtothesubregionalandregional

levels.Wedevelopedcertaintyintervalstoaccountfortheremainingimprecision

intheestimates.

Changesinabortionincidencebetween1995and2008arenotexplainedbythe

agedistributionofwomen1544worldwide.Theproportionof1544yearolds

whoareaged1529years(theagerangeatwhichabortionismostprevalent)

[33,34]declinedbylessthan4%overthese13years[35]whereastheabortion

rateper1000womenaged1544yearsdeclinedby19%.Othertrendsthatcould

affecttheabortionrate,andforwhichrepresentativedataatthesubregionaland

regionallevelsarenotreadilyavailable,includeariseinwomensageatmarriage,


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increasedprevalenceofsexualactivityamongunmarriedwomen,andgrowing

proportionsofwomeninthelaborforceresultinginmoreprevalentandmore

stronglyhelddesirestocontrolthetimingofbirths.

We

found

that

the

proportion

of

women

living

under

liberal

abortion

laws

is

inverselyassociatedwiththeabortionrateinthesubregionsoftheworld.Other

studieshavefoundthatabortionincidenceisinverselyassociatedwiththelevel

ofcontraceptiveuse,especiallywherefertilityratesareholdingsteady,[3638]

andthereisapositivecorrelationbetweenunmetneedforcontraceptionand

abortionlevels.[36]Theunmetneedformoderncontraceptionislowerin

subregionsdominatedbyliberalabortionlawsthaninthosedominatedby

restrictivelaws,andthismighthelpexplaintheobservedinverseassociation

betweenliberallawsandabortionincidence.[39]Globallevelsofunmetneed

andcontraceptiveuseseemtohavestalledinthepastdecade:thepercentof

marriedwomenwithunmetneedforcontraceptionfellby02percentagepoints

peryearin19902000,butessentiallydidnotchangein20002009.[39]Family

planningservicesseemtonottobekeepingupwiththeincreasingdemand

drivenbytheincreasinglyprevalentdesireforsmallfamiliesandforbetter

controlofthetimingofbirths.[40]

The

most

recent

progress

report

on

the

MDGs

shows

that

the

gap

between

developedanddevelopingcountriesislargestwithrespecttomaternalhealth.

[41]Thisgapismirroredinthesharpdifferenceintheincidenceofunsafe

abortionbetweenthedevelopedanddevelopingregions.Withindeveloping

countries,moreliberalabortionlawsareassociatedwithfewerhealth

consequencesfromunsafeabortion.Abortionmortalityfellgreatlyafterthe

liberalizationoftheabortionlawinSouthAfrica.[42,43]InNepal,whereabortion

wasmadelegalonbroadgroundsin2002,abortionrelatedcomplicationsfell

from54%to28%ofallmaternalmorbiditiestreatedatrelevantfacilitiesbetween

1998and2009.[44]Recentnationaltrendsinabortionrelatedmorbidityand

mortalityinEthiopia,wherethelawwasliberalizedin2005,arenotyetknown,

butaccesstoequipmentandtrainingofprovidersinsafeabortioncareincreased

since2005,[45]andastudyinonelargehospitalfoundthattheratioofabortion

complicationstolivebirthsdeclinedsignificantlybetween2003and2007.[46]


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Variousdevelopingcountrieshavebroadenedthegroundsunderwhichabortion

islegalinrecentyears.[47]However,aliberalabortionlawalonedoesnotensure

thesafetyofabortions.Othernecessarystepsincludethedisseminationof

knowledgeaboutthelawtoprovidersandwomen,thedevelopmentofhealth

serviceguidelinesforabortionprovision,thewillingnessofproviderstoobtain

trainingandprovideabortionservices,andgovernmentcommitmenttoprovide

theresourcesneededtoensureaccesstoabortionservices,includinginremote

areas.

Althoughresearchindicatesthattheannualnumberofmaternaldeathshas

declinedinrecentyears,theWHOestimatesthattheproportionofmaternal

deathsduetounsafeabortionremainedat13%in2008asin2003.[4]Deathdue

tounsafeabortionremainsanimportantandavoidableoccurrence,asdothe

healthandsocialandeconomicconsequencesofunsafeabortion.[12,48]

Constraintsonaccuratelymeasuringabortionlevelshavebecomemoreprevalent

overtheyearswhereprivatesectorabortions,medicalabortions,andthe

stigmatizationofabortionhavebecomemorecommon,asallthesefactorstend

toincreasethelevelofunderreporting.Ifabortionestimationistoremain

feasible,investmentsmustbemadeinfurtherrefiningandapplyingresearch

methods

for

measuring

abortion

incidence.

Wefoundthatabortionscontinuetooccurinmeasurablenumbersinallregions

oftheworld,regardlessofthestatusofabortionlaws.Unintendedpregnancies

occurinallsocieties,andsomewomenwhoaredeterminedtoavoidan

unplannedbirthwillresorttounsafeabortionsifsafeabortionisnotreadily

available,somewillsuffercomplicationsasaresult,andsomewilldie.Measures

toreducetheincidenceofunintendedpregnancyandunsafeabortionincluding

improvingaccesstofamilyplanningservicesandtheeffectivenessof

contraceptiveuse,andensuringaccesstosafeabortionservicesandpost

abortioncarearecrucialstepstowardachievingtheMDGs.


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ContributorsGSandEAcompiledinformationsourcesandledtheestimationoftheincidenceofsafeabortion(GS)andunsafeabortion(EA).SS,IHS,SKH,andABprovidedtechnicalassistanceduringthedatacollectionandestimationofabortion

incidence.

GS

wrote

and

revised

the

report.

All

other

authors

provided

substantiveinputondraftsofthereport.Allauthorshaveseenandapprovedthefinalversionofthereport.

AcknowledgmentsThisstudywasfundedbytheUKDepartmentofInternationalDevelopment,the

DutchMinistryofForeignAffairs,andtheJohnDandCatherineTMacArthur

Foundation.Theestimationofunsafeabortionwasdevelopedandcommissioned

byWHOandsomeoftheseestimateshavebeenpublishedpreviously.4The

estimationofsafeabortionandthecompilationofworldwidelevelswasledby

theGuttmacherInstitute.Theauthorsaloneareresponsiblefortheviews

expressedinthispaperandtheydonotnecessarilyrepresentthedecisions,

policy,orviewsoftheirinstitutionsorthoseoffundingagencies.WethankAlyssa

Tartaglione,RubinaHussain,andMichelleEilersfortheirassistancewith

obtainingandmanagingdataandpreparingthemanuscript.


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Region and Subregion 2008 2003 1995

World 43.8 41.6 45.6

Developed countries(2)

6.0 6.6 10.0

Excluding Eastern Europe 3.2 3.5 3.8

Developing countries(2)

37.8 35.0 35.5

Excluding China 28.6 26.4 24.9

Africa 6.4 5.6 5.0

Eastern Africa 2.5 2.3 1.9

Middle Africa 0.9 0.6 0.6

Northern Africa 0.9 1.0 0.6

Southern Africa 0.2 0.3 0.2

Western Africa 1.8 1.5 1.6

Asia 27.3 25.9 26.8

Eastern Asia 10.2 10.0 12.5

South-central Asia 10.5 9.6 8.4

South-eastern Asia 5.1 5.2 4.7

Western Asia 1.4 1.2 1.2

Europe 4.2 4.3 7.7

Eastern Europe 2.8 3.0 6.2

Northern Europe 0.3 0.3 0.4

Southern Europe 0.6 0.6 0.8

Western Europe 0.4 0.4 0.4

Latin America 4.4 4.1 4.2

Caribbean 0.4 0.3 0.4

Central America 1.1 0.9 0.9

South America 3.0 2.9 3.0

Northern America 1.4 1.5 1.5

Oceania 0.1 0.1 0.1

1Regions and subregions as defined by the United Nations.

2Developed regions are defined here to include Europe, North America, Australia,

Japan and New Zealand; all others are classified as developing.

Estimates by region and subregion

Table 1. Estimated number of induced abortions (in millions) worldwide and

by region, subregion and year.


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Region and Subregion Total Safe Unsafe % Unsafe Total Safe Unsafe % Unsafe Total

World 28 14 14 49 29 15 14 47 35

Developed countries 24 22 1 6 25 24 2 7 39Excluding Eastern Europe 17 17 ^ ^ 19 18 1 3 20

Developing countries 29 13 16 56 29 13 16 55 34

Excluding China 29 8 22 74 30 8 22 73 33

Estimates by region and subregion

Africa 29 1 28 97 29 ^ 29 98 33

Eastern Africa 38 2 36 96 39 ^ 39 100 41

Middle Africa 36 ^ 36 100 26 ^ 26 100 35

Northern Africa 18 ^ 18 98 22 ^ 22 100 17

Southern Africa 15 7 9 58 24 5 18 77 19

Western Africa 28 ^ 28 100 27 ^ 27 100 37

Asia 28 17 11 40 29 18 11 38 33

Eastern Asia 28 28 ^ ^ 28 28 ^ ^ 36

South-central Asia 26 9 17 65 27 9 18 66 28

South-eastern Asia 36 14 22 61 39 16 23 59 40

Western Asia 26 11 16 60 24 16 8 34 32

Europe 27 25 2 9 28 25 3 11 48

Eastern Europe 43 38 5 13 44 39 5 12 90

Northern Europe 17 17 ^ ^ 17 17 ^ ^ 18

Southern Europe 18 18 ^ ^ 18 15 3 18 24

Western Europe 12 12 ^ ^ 12 12 ^ ^ 11

Latin America 32 2 31 95 31 1 30 96 37

Caribbean 39 21 18 46 35 19 16 45 50

Central America 29 ^ 29 100 25 ^ 25 100 30

South America 32 ^ 32 100 33 ^ 33 100 39

Northern America 19 19 ^ ^ 21 21 ^ ^ 22

Oceania 17 14 2 15 18 15 3 16 21

* Abortions per 1,000 women aged 15-44.

^ Rate or percent less than 0.5.

Table 2. Estimated safe and unsafe abortion rates* worldwide and by region, subregion and year.

2008 2003


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Region and Subregion 2008 2003 1995

World 21 20 22

Developed countries 26 28 36Excluding Eastern Europe 17 19 20

Developing countries 20 19 20

Excluding China 18 17 16

Estimates by region

Africa 13 12 12

Asia 22 22 21

Europe 30 32 42

Latin America 25 22 23

Northern America 19 21 22

Oceania 14 16 17

*Pregnancies include live births, abortions and miscarriages.

Table 3. Estimated percent of all pregnancies* that ended in abortion,

worldwide and by region, subregion and year.


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0

10

20

30

40

50

60

1990 1995 2000 2005 2010Abortionsper1,0

00women

15

44

Year

Figure1.Trendsinabortionratebygeographicregion,1995to2008

Africa

Asia

Europe

LatinAmericaNorthernAmericaOceania


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0

10

20

30

40

50

60

0 20 40 60 80 100

Abortionsper1,0

00women15

4

4

%ofwomen1544livingunderliberalabortionlaws

Figure2.Theassociationoftheabortionratewiththe

prevalenceofliberalabortionlawsbysubregion,2008.

induced abortion: incidence and trends worldwide from 1995 to 2008

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