Abortion: access and safety worldwide

Abstract

44% of the world's annual 227 million pregnancies are unintended, of which 56% end in abortion, 32% in an unplanned birth, and 12% in miscarriage. These estimates—from a modelling study authored by the Guttmacher Institute and the University of Massachusetts and published by The Lancet Global Health—form the basis of a Guttmacher report on global abortion published on March 20. This analysis was last performed in 2009, since when the rate of unintended pregnancy and abortion in high-income countries has fallen significantly, concurrent with both an increase in the rate of modern contraception usage and a decrease in the number of unintended pregnancies ending in abortion. Low-income and middle-income countries have a higher abortion rate than high income countries, and there has been no significant change in the rate since the 1990s. Unsafe abortions cause 8–11% of global maternal deaths and occur predominantly in low-income and middle-income countries where the most restrictive access policies are concentrated and socioeconomic factors further affect access. Since 2009, the report concludes, a significant rise in medication abortions (using the combination of mifepristone and misoprostol, or misoprostol alone) has substantially improved the safety of clandestine abortions. Misoprostol, which is also used to treat gastric ulcers and therefore often relatively widely available, is now the most common method of abortion in many countries with restricted access. In high-income countries, which usually have the most liberal access policies, the vast majority of abortions are conducted under safe conditions. Many high-income countries have transitioned from majority surgical to majority medication abortions (using the more efficacious combination of misoprostol and mifepristone). This transition, in combination with increasing early detection of pregnancy, has increased the rate of early and very early abortions. The high cost of mifepristone and lack of an alternative mean that surgical vacuum aspiration still predominates in some high-income countries—for example, Germany. Since 2000, 27 countries have expanded the legal grounds for abortion, and only one country (Nicaragua) has restricted access. However, in countries where abortion is legally permitted, access can be compromised in several ways. In the USA, since 2010, 32 states have collectively enacted 338 laws restricting access to legal abortion. On March 16, the National Academies of Sciences, Engineering, and Medicine (NASEM) released a comprehensive review of the safety and the quality of abortion care in the USA. The committee who conducted this study concluded that legal abortions in the USA are safe and effective. However, they found that abortion-specific state regulations have created barriers to optimal care for US women and that quality of care was highly dependent on where women lived. 39% of US women of reproductive age currently live in states with no abortion provider and the number of facilities continues to decrease, with the greatest proportional decline in states with the most abortion-specific legislation. The evidence behind some of these state limitations of otherwise legal abortion services is examined by NASEM. The committee recommends that most abortions could safely be carried out in office-based settings, with requirements depending, as for other procedures, on the level of sedation necessary. Providing that the practitioner could arrange safe transfer if complications arose, the committee found that trained physicians, physician's assistants, nurse-midwives, and nurse practitioners could all perform medication and aspiration abortions safely and effectively, without the need for hospital privileges. The committee also recommended further research around the restricted distribution of mifepristone and its potential impact on timeliness, patient centredness, and equity. Surgical abortion procedures still predominate in the USA, with aspiration accounting for 68% of all abortions in 2013. Abortion has become the subject of a highly politicised debate and of the worst kind of value signalling from those in positions of power, who are often protected from the consequences of their policies by gender, geography, and economics. The burden of unintended pregnancies falls hardest on the most vulnerable women. Reducing the stigma, minimising the social and economic consequences of unintended pregnancies, improving access to highly effective modern contraception, and ensuring legal and safe abortions would generate tangible improvements to health. Those with real motivation to protect and support women and children should look to research, not misconceptions, to inform decision making.