Many of us here in Europe and Australia are watching in horror as the US Supreme Court moves towards taking away the reproductive freedom of US women. And from the noises being made by Republican politicians, access to contraceptives, gay marriage and any other human rights not recognized in the 16^th century are at risk also.

During my close to two decades responsible for WHO global health statistics, I worked closely with the maternal health department on regular assessments of maternal mortality, including deaths due to unsafe abortion. My team collaborated with the Guttmacher Institute on several occasions to produce global statistics on induced abortion. Given the current situation, I was interested to see that the Guttmacher Institute and WHO released first-ever country-level estimates of unintended pregnancy and abortion (see here) a little under two months ago.

The new study analysed data for 150 countries for the period 2015-2019, and found that:

The Guttmacher/WHO study covers 90% of the 1.9 billion women of reproductive age. Almost all the missing countries (because of lack of data) are in the Western Asia and Northern Africa region, most of them Islamic states or with a dominant Islamic culture. I describe elsewhere how I imputed data for most of the missing countries and added data on legal grounds and restrictions regarding abortion. Countries classified as having abortion restrictions are those which completely prohibit abortion or allow abortion only on one or more of the following grounds: risk to life, risk to health, rape or fetal impairment. Countries classified as without abortion restrictions also allowed abortion on social or economic grounds, or on request. Given the polarization of the US states in allowing or restricting abortion, I also used information from Planned Parenthood to classify US states into two groups with and without restrictions.

First, a brief overview at the global level of the differences between grouped countries with and without restrictions:

• 36% of women of reproductive age live in countries with restricted access to abortion. These countries account for 33% of global abortions, 50% of global live births and 81% of global maternal deaths.
• The global abortion rate per 1,000 women aged 15-49 years is 31 for countries with restrictions and 41 for countries without restrictions.
• 21% of pregnancies are terminated by abortion in countries with restrictions, 34% in countries without restrictions.
• Average GDP per capita (purchasing power parity dollars) was $18,300 in countries without restrictions, and 71% of women aged 15-49 used modern forms of contraception.  For countries with restrictions, the average GPD/capita was $8,500 and only 57% of women used modern forms of contraception.
• Countries restricting abortion were much more religious with 66% of adults attending religious services at least once a month, compared to 27% in countries not restricting abortion (data on religious practice from the World Values Survey and European Values Study, see earlier post here).

These global averages conceal very large differences across regions, and between countries in some regions.  I have examined these patterns by grouping countries into 11 culture zones, based on those developed by Welzel (2013) for the World Values Survey.

I modified the culture zones slightly, to include Canada in the Reformed West and keep the USA in its own separate category. I also moved predominantly Muslim countries from “Indic East” and “Sinic East to group together all countries with a predominantly Islamic culture and values. See here for full definitions of the culture zones.

The left-hand figure 1 shows that abortion is universally legally available in most of Europe, Canada, Australia and New Zealand, in the Orthodox and Islamic countries of the former Soviet-bloc and in the non-Islamic countries of Asia. It is legally severely restricted in most Islamic countries and sub-Saharan Africa. Abortion rates are substantially lower in the high-income countries of Europe, North America and Australia and New Zealand than in the Asian regions where abortion is unrestricted AND in the countries in all developing regions irrespective of whether abortion is legally restricted or available. Note that USA results have been calculated by grouping States into those with and without significant abortion restrictions.

For 2015-2019, almost half of unintended pregnancies (46%) were aborted in countries where abortion was restricted (often severely) and a little over two-thirds (70%) in countries where abortion is accessible.  In the three regions where around 40-50% of women with unintended pregnancies have restricted access to abortions, overall abortion rates per 1,000 women of reproductive age differ by less than 2 abortions per 1,000 from those in countries (or US states) without restrictions. These are the USA (11 versus 13 per 1,000), the Returned West (11 versus 10 per 1,000) and Latin America (30 versus 31 per 1,000). The Returned West consists of former Soviet-bloc countries that have joined the EU, and the largest of these, Poland, is the only one to have restricted abortion, prohibiting it for fetal impairment, economic or social reasons, or on request.

People seek and obtain abortions in all countries, even in those with restrictive abortion laws, where barriers to safe abortion care are high. In fact, over the past three decades, the proportion of unintended pregnancies that end in abortion has increased in countries that have many legal restrictions in place. The figures presented above suggest that the illegalization of abortion will not substantially reduce its incidence.  Over recent decades, most of the changes to the legal grounds for abortion have been in the direction of recognizing women’s rights to reproductive autonomy (recent examples include Ireland, Argentina, Mexico and Columbia).

The increasing restrictions in the USA are one of the few examples of major reductions in women’s rights occurring outside the Islamic countries. In the case of the USA, these changes are to rights that women have had for half a century and are being driven by an anti-democratic coalition of white nationalists and religious extremists who do not represent the majority views of the population. A recent issue of the Economist identified white evangelicals as the one major religious group with majority opposition to the legal availability of abortion (The Economist, May 7, 2022). A majority of Catholics, mainline Protestants and those with no religious identification think that abortion should be mostly or always legal in the USA, and support is over 75% for Jewish, atheists and non-religious with college education.

The rhetoric of some US extremists, and actions already taken to restrict health insurance coverage for contraceptive use, suggests that further restriction on abortion access may well also be accompanied by further reductions in contraceptive availability. The unintended pregnancy rate may well increase, resulting in an overall increase in numbers of abortions occurring, even if the restrictions reduce the percentage of unintended pregnancies that end in abortion. In my next post, I will examine differences in maternal mortality across countries and the extent to which they are associated with legal restrictions on abortion.