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.
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