Tag Archives: World Health Organization

Maternal mortality and abortion restrictions

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In my previous post, I estimated that 47% of pregnancies are unintended, and of these, 43% occur in countries where abortion is illegal or severely restricted. In countries where abortion is widely available, 71% of unintended pregnancies are aborted compared to 46% in countries with severe restrictions. 

The World Health Organization (WHO) estimates that around one-third of the 23 million induced abortions carried out each year in countries where abortion is severely restricted are performed under the least safe conditions, by untrained persons using dangerous and invasive methods. Safe abortion is an essential health care service. It is a simple intervention that can be effectively managed by a wide range of health workers using medication or a surgical procedure. In the first 12 weeks of pregnancy, a medical abortion can also be safely self-managed by the pregnant person at home.

Maternal mortality is defined as death while pregnant or within 42 days of the end of pregnancy from any cause related to or aggravated by the pregnancy or its management. The plot above shows the average maternal mortality ratio (MMR) per 1,000 live births for countries (and US states) grouped by access to abortion and culture zone for the year 2017 (see here for more details).

While countries that restrict abortion have higher MMRs than those that don’t for most of the culture zones, we cannot conclude that abortion restriction per se is responsible for the difference. Abortion restriction is also correlated with other determinants of higher MMR such as lower average income per capita, less access to health care, and higher levels of discrimination against women.

The global MMR has declined from 345 per 100,000 livebirths in 2000 to 212 per 100,000 livebirths in 2017, a 40% decrease in 17 years.  There have been substantial declines in MMR in every culture zone except for the Reformed West and Old West where MMR rates were already very low in 2000 and in the USA where rates have risen substantially during the 21st century.

The plot below takes a closer look at MMR trends in the USA, the Reformed and Old West, the Returned West and the Orthodox East. The latter two culture zones include the former Soviet bloc countries. With the exception of Poland in the Returned West, all these culture zones except the USA do not restrict access to abortion services and allow abortion on request or in some countries on “economic and social grounds”.

The maternal mortality ratio for the USA has increased from around 15 per 100,000 livebirths in 2000 to 23.8 in 2020, a 62% increase.  Abortion rates in States which now restrict abortion were similar to those in states which don’t until 2008 and afterwards diverged substantially. The rate for states with restrictions was 26.4 in 2020, 30% higher than the MMR of 20.2 for states without restrictions.

There has been considerable controversy about the substantial increase in maternal mortality in the USA, particularly as to whether it is associated with improvements in the identification and reporting of maternal deaths.  The addition of a pregnancy checkbox to death records from 2003 onwards is thought to have led to some increase in estimated MMRs in the early 2000s, but several studies have also identified that increasing restrictions on the general availability of reproductive health services have played a major role, particularly in states restricting access to abortion.

Hawkins et al (2019) found that a 20% reduction in the numbers of Planned Parenthood clinics resulted in an 8% increase in maternal mortality and states that enacted legislation to restrict abortions based on gestational age increased the maternal mortality rate by 38%.

A 2020 study by the Commonwealth Fund compared maternity care in the USA with 10 other developed countries and found that the USA has the highest maternal mortality among developed countries and that there is an overall shortage of maternity care providers (obstetrician-gynecologists and midwives). The USA has 12 to 15 providers per 1,000 livebirths, and all the other developed countries have a supply that is between two and six times greater. Although a large share of its maternal deaths occur postbirth, the U.S. is the only country not to guarantee access to provider home visits or paid parental leave in the postpartum period. In the early 2000s, WHO estimated that unsafe abortion accounted for around 13% of total global maternal deaths, then estimated to be around half a million deaths per year.  A more recent study by WHO staff and academic colleagues in 2014 estimated that abortion accounted for 7.9% of maternal deaths at global level between 2003 and 2009. Recent WHO estimates for global deaths by cause do not include deaths due to induced abortion. I have elsewhere used results from the Global Burden of Disease Study 2019 to estimate very approximately the proportion of maternal deaths due to abortion and miscarriage for the period 2015-2019. These would include induced abortion deaths as well as deaths due to spontaneous abortions and miscarriages.  The following plot shows the estimated average percent of maternal deaths attributed to abortion and miscarriage for countries with and without abortion restrictions in each culture zone.

Overall, I estimate that there were 75,500 deaths globally due to abortion and miscarriage in 2017 (these include spontaneous events as well as induced abortions). Of these 70,300 were in countries with abortion restrictions. Assuming the rate in countries with unrestricted abortion relates to the spontaneous events, I have estimated that abortion restrictions resulting in unsafe abortions caused 54,350 deaths in 2017.  If all abortions were safe, there would have been only 21,200 deaths globally due to spontaneous abortion and miscarriage in 2017.

Its quite possible these very back-of-the-envelope estimates are under-estimates. Classification of maternal deaths due to abortion, and more specifically unsafe abortion, is associated with a risk of misclassification. Even where induced abortion is legal, religious and cultural perceptions in many countries mean that women do not disclose abortion attempts and relatives or health-care professionals do not report deaths as such.

A medical abortion procedure uses the drugs mifepristone and misoprostol which can be taken in pill form up until the 12th week and are very safe. They require no surgery or anaesthesia. These drugs were developed in 1980 and first became available for induced abortions in France in 1987. It became available in the USA in 2000 and is on the WHO list of essential medicines. Cost and availability limits access in many parts of the developing world.

It is usually possible to carry out this procedure oneself at home. During the covid pandemic, a number of countries including the UK have made abortion accessible via an online consultation after which the pills are sent by post to the woman to take at home. The Netherlands-based charity Women on Web aims to prevent unsafe abortions by providing abortion pills to women in countries where safe abortion is available.

In December 2021, the FDA made permanent a covid-era policy allowing abortion pills to be prescribed via telehealth and distributed by mail in US states that permit it.Even before the FDA action,abortions induced by pills rose to more than 54 percent of all U.S. abortions in 2020, according to the Guttmacher Institute. Nineteen states have banned prescription of these pills via online consultation, requiring the woman visit a physician. And of course, in states which severely restrict abortion, this will require a completely unnecessary trip out of state.

Women on Web is making medical abortion available to women in the USA and elsewhere who are facing these restrictions. The cost for a woman to obtain the pills for a medical abortion is 90 Euros, or around 100 US dollars. You can donate to fund abortions for women unable to afford them here. Or to US based abortion funds here.

While legal abortions done under the guidance of a professional are the gold standard. Self-managed abortion can be safe, too, if you have the right information. But as I noted above, the banning of abortion typically goes hand-in-hand with restrictions on contraception and reproductive health services, as well as discrimination and other restrictions on women that result in higher maternal mortality rates, more femicide and abuse, less access to education and employment, and greater female poverty levels.

The removal of a basic reproductive rights for women in the USA is being driven by a minority, many of whom are fundamentalist Christians. According to a recent survey, white and Hispanic fundamentalists are the only religious group in the USA for which a majority oppose the legal availability of abortion (The Economist, May 7, 2022).

I discussed in a previous post how enforcement of social norms governing human fertility have been a major factor in pre-modern religions. For thousands of years, very high levels of child mortality and other survival pressures meant that most societies sought to ensure that women produced as many children as possible and discouraged divorce, abortion, homosexuality and contraception. Additionally sexual behaviour, particularly that of women and that not linked to reproduction, was strongly socially controlled to minimise uncertainty about paternity. Religion was the primary method of social control and pre-modern values regarding women’s rights, reproduction and sexuality are still dominant in most of the major religions, particularly fundamentalist forms. In a world facing overpopulation, global warming, habitat destruction and species extinction, it is crucial that outdated and cruel pre-modern values do not condemn women to reproductive slavery and an inability to control their own fertility, and reduce our ability to address these inter-related crises using all the tools and knowledge now available.

Global variations in abortion legality and rates

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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 16th 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:

  • Almost half of the 220 million pregnancies globally per year are unintended.
  • Six in 10 unintended pregnancies end in an induced abortion (63 million per year).
  • Overall, 29% of all pregnancies globally end in an induced abortion.
  • Regional averages mask large disparities within regions for unintended pregnancy and abortion rates.

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.

Figure 1
Figure 2.

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.