Abortion Around the World

Throughout the world abortion is used regularly as a method of birth control. Because women are fertile for almost half of their lives, many have unwanted pregnancies at one time or another. Regardless of whether abortion is legal, women in all countries and cultures have relied on abortion to control childbirth. Abortion rates around the world generally reflect the religious and political power in the country, the cultural values, and the availability of contraception.

The major organizations that compile international abortion statistics are the Alan Guttmacher Institute (AGI) of New York, an organization that supports a woman's right to choose abortion, and the World Health Organization (WHO) of the United Nations. In countries where abortion is illegal or severely restricted, it is impossible to know how many women get private abortions and how many of those who turn up at the hospital with a "spontaneous abortion" (miscarriage) actually have induced the abortion through a home method. Also, many countries where abortion is legal do not keep complete medical records. The abortion and health data that is available for other countries is often not as current at that for the United States.

The WHO reports that each year, 210 million women throughout the world become pregnant. Of these pregnancies, forty-six million (22%) end in abortion, and twenty million of these abortions are estimated to be "unsafe." A great number of women either do not want any more children or do not want a child at that time. According to the AGI in "Induced Abortion Worldwide: Facts in Brief," (http://www.agi-usa.org/pubs/fb_0599.html), each year in developed countries about half (49%) of the twenty-eight million pregnancies that occur are unwanted. About one-third (36%) end in abortion. In developing countries approximately one-third (36%) of pregnancies are unwanted. One-fifth (20%) end in abortion.

ABORTION LAWS WORLDWIDE

The Center for Reproductive Rights, which supports a woman's right to choose, reported in "The World's Abortion Laws" (June 2004) that 61% of people live in countries where abortion is permitted for a wide range of reasons or without restriction. About one-fourth (26%) of the world's population, however, live in countries that generally forbid abortion. Countries are categorized based on the restrictiveness of abortion laws, as follows (see Table 8.1):

• Prohibited altogether or permitted only to save the woman's life—There are seventy-two countries (26.1% of the world's population) in this category. As the map in Figure 8.1 shows, most countries with highly restrictive laws are in Central and South America, Africa, the Middle East, and Indonesia.
• To preserve the woman's physical health (and to save her life)—Thirty-five countries (9.9%) allow an abortion if it threatens a woman's physical health. These types of laws sometimes require that the potential injury be either serious or permanent.
• To preserve the woman's mental health (and to preserve her physical health and save her life)—Twenty countries (2.7%) allow the termination of pregnancy if continuing it would jeopardize a woman's mental health. However, what constitutes a threat to mental health varies from country to country, from psychological distress caused by rape to mental anguish because the woman is carrying a fetus that might have abnormalities.
• Socioeconomic grounds (also to save the woman's life, physical health and mental health—Fourteen countries (20.7%) permit abortion, but consider a woman's economic resources, her age, whether she is married, and the number of children she already

• has. Barbados, Great Britain, India, and Zambia have laws in this category. These laws usually are interpreted liberally.
• Without restriction as to reason—Fifty-four countries, where 40.5% of the world's women live, allow abortion without limiting the reasons for pregnancy termination.

In addition, in some countries a woman may obtain a legal abortion based on "juridical grounds" (rape or incest) or "fetal impairment grounds" (probable genetic defects). Countries that recognize these grounds for legal abortion may be classified under any of the five categories of restrictiveness. Access to abortion also may be limited by spousal or parental consent laws.

Abortion Limitations Even When Laws Are Liberal

In the countries where abortion is not restricted as to reason, and in the countries that allow abortion based on socioeconomic grounds, the laws usually mandate certain conditions for allowing the abortion. According to the Center for Reproductive Rights (Crafting an Abortion Law That Respects Women's Rights: Issues to Consider, Briefing Paper, http://www.reproductiverights.org/pdf/pub_bp_craftingabortionlaw.pdf, August 2004), these countries may impose gestational limits; consent, counseling, and waiting-period requirements; fetal-age restrictions; limitations on advertising abortion services; and limitations on the place of abortion and the person performing the procedure. For example, a woman in Turkey needs her husband's permission; in Germany a woman is required to receive counseling that is intended to discourage her from having the abortion; and in Belgium the waiting period is six days. Most countries set fetal age limits of seeking an abortion with the least restrictions at an upper limit of twelve to fourteen weeks.

COMPARISONS OF ABORTION STATISTICS WORLDWIDE

Stanley K. Henshaw, Susheela Singh, and Taylor Haas of the AGI reported in "The Incidence of Abortion Worldwide" (International Family Planning Perspectives, vol. 25, Supplement, January 1999), that in 1995 an estimated 45.5 million abortions were performed around the world. Nearly 26.0 million were legal and 19.9 million were illegal. The overall worldwide abortion rate was thirty-five abortions per one thousand women ages fifteen to forty-four. About one-quarter (26%) of all pregnancies ended in abortion. (See Table 8.2.)

Regional Estimates

Asia accounted for the largest number of abortions (26.8 million), which corresponds to 59% or three of every five abortions worldwide. Europe was the region with the second most abortions (7.7 million), followed by Africa (5.0 million), Latin America (4.2 million), North America (1.5 million), and Oceania (0.1 million). (See Table 8.2.)

Europe, where abortions are generally legal, had the highest abortion rate of any region—forty-eight abortions per one thousand women ages fifteen to forty-four. In Europe nearly half (48%) of all pregnancies ended in abortion, compared with 15% in Africa. Europe encompassed the two subregions with the highest and lowest rates—eastern Europe, with ninety abortions per one thousand women, and western Europe, with eleven abortions per one thousand women ages fifteen to forty-four. Among the subregions, eastern Europe accounted for the highest proportion (65%) of pregnancies terminated by abortion.

Country Estimates

Table 8.3 illustrates the abortion numbers, rates, and ratios for countries with populations exceeding one million for which the AGI obtained information using available national statistics and surveys. The authors pointed out that the upper category, "Believed to be complete," includes countries for which the abortion statistics are thought to be within 20% of the actual numbers. The lower "Incomplete" category includes countries whose statistics may be inaccurate by at least 20% or whose data may not be complete.

Among countries where abortion is legal and data are believed to be complete, Cuba, Belarus, and Estonia had the highest abortion rates—77.7, 67.5, and 53.8 abortions per one thousand women ages fifteen to forty-four, respectively. The Netherlands (6.5 per one thousand women) and Belgium (6.8 per one thousand women) had the lowest abortion rates, followed by Germany (7.6 per one thousand women) and Switzerland (8.4 per one thousand women). Women in Belarus, Cuba, and Estonia were the most likely to choose to terminate their pregnancies with abortion, as these countries also had the highest abortion ratios. Nearly two-thirds (61%) of all pregnancies ended in abortion in Belarus, followed by 58.6% in Cuba and 56% in Estonia. Only about one in ten women in the Netherlands (10.6%) and Belgium (11.2%) terminated their pregnancies with abortion, and women in Tunisia were least likely to choose abortion (7.8%).

Among countries where abortion is legal but the data are incomplete, the authors surmised that the actual abortion rates are higher than shown in Table 8.3. Henshaw, et al., noted that the actual rates for Vietnam (83.3 per one thousand women) and Romania (78.0 per one thousand women) probably were higher because only public-sector abortion numbers were available in the AGI survey. China's real rate of abortions per one thousand women is more likely to be between thirty and thirty-five abortions, not the official rate of 26.1. Unofficial surveys of women in Japan tend to indicate that the abortion rates probably exceeded twenty abortions per one thousand women rather than the reported 13.4 abortions per one thousand women. Similarly, Bangladesh's and India's reported rates of 3.8 and 2.7 abortions per one thousand women, respectively, are more likely to be several times these numbers.

Of those countries with incomplete or questionable data, the highest estimated proportion (ratio) of pregnancies terminated by abortion occurred in Russia and Romania and were about 63% each. (See Table 8.3.)

In countries where abortion is illegal, the AGI estimated the number of induced abortions, basing their figures on such factors as the proportion of women hospitalized as a result of complications and on surveys conducted by health-care professionals. The authors, however, warned that even in cases where women sought hospitalization, many other factors came into play, including "the extent to which safe abortion is practiced, the probability of complications arising from procedures provided by nonphysicians and the ease of access to a hospital."

Of abortions performed in Western industrialized countries, Australia has the highest rates of abortion, at 22.2 per one thousand. This is followed closely by the United States at 21.3 per one thousand. The Netherlands had the lowest abortion rate, at 6.5 per one thousand.

Abortion Laws and Rates

Worldwide, women have abortions whether laws are restrictive or not, and the rate of abortion is not higher in countries where abortion is permitted. Table 8.4 compares the rate of abortion in six countries with liberal abortion laws to the rate of abortion in eight countries with severely restricted abortion laws. Among these countries, the rate of abortion is much higher in the countries with restrictive laws compared with countries with more permissive laws, in spite of the fact that abortions in countries with restrictive abortion laws are generally illegal and often unsafe.

ABORTION IN SELECTED COUNTRIES

Poland

The collapse of Communism in Poland in 1989 led to the prohibition of abortion, which had been legal since 1956. As soon as Lech Walesa's Solidarity Party gained control of the parliament, it amended the existing abor-tion, law. Strongly supported by the Roman Catholic Church, the new statute severely restricted access to abortion, requiring a woman requesting a state-funded abortion to present written approval from three physicians and a psychologist from a state-approved list of doctors.

The new abortion provision granted physicians and hospital staffs in public hospitals the right to refuse to perform abortions. As a result, the number of abortions in state-funded hospitals fell from 105,300 in 1988 to about thirty-one thousand in 1991, according to figures provided by the Polish government. In addition, the state stopped funding contraceptives for the poor, and funding was reduced for the Polish affiliate of the International Planned Parenthood Association, resulting in the closing of half of its offices.

In March 1993 a new antiabortion law, granting protection to a fetus from the moment of conception, went into effect. The law allowed abortion only if the pregnancy seriously threatened a woman's life or health, in cases of rape or incest, or if the fetus had irreparable abnormalities. Private clinics were forbidden to perform abortions, and physicians performing illegal abortions could be imprisoned for up to two years. If the woman died of complications, a physician could face up to ten years' imprisonment. Women who had abortions were not punishable.

The new law also required that the Catholic Church be involved in reproductive services and that sex educa-tion be based on "family and conceived-life values as well as on methods and means of conscious procreation." "Conscious procreation" meant contraception, but little information on contraception was delivered by health professionals, other than information on withdrawal and rhythm methods, which were accepted by the Catholic Church.

The government reported that 782 legal abortions were performed in 1994 in Poland. Pro-choice organizations, however, estimated that forty thousand to fifty thousand Polish women had abortions abroad or at home illegally.

In November 1995 Lech Walesa lost the presidential election to pro-choice candidate Aleksander Kwasniewski. Although about 90% of Poles are Catholic, a number of surveys have found that most favored liberalization of Poland's restrictive abortion laws.

A year later, in November 1996, the Polish government again legalized abortion. The new law permitted women to obtain an abortion until the twelfth week of pregnancy if they were financially or emotionally unprepared for childbirth. A woman seeking an abortion was required to obtain counseling and wait three days before having the procedure. The new law forbade abortion against a woman's will or after the fetus had become viable (able to survive outside the womb). The law further addressed the abortion issue by providing for government funding of oral contraceptives and sex education.

In May 1997 Poland's highest court, the Constitutional Tribunal, struck down the 1996 abortion law, declaring the provision allowing abortions "for compelling social and financial reasons" unconstitutional. The Tribunal ruled that "the first article of our Constitution names Poland as [a] democratic state based on the rule of law. The highest value in a democracy is human life, which must be protected from its beginning to the end." In December 1997 the newly elected Parliament, dominated by pro-Church legislators, reinstated the strict 1993 antiabortion law. Under this law abortions are allowed only in cases of life endangerment, rape, or incest or if the fetus is damaged irreparably.

During the campaign for the 2001 general election, the Democratic Left Alliance promised to liberalize abortion. Although they won the election, laws were not changed because Poland sought the support of the Roman Catholic Church to join the European Union, which the Church would offer only if the existing abortion law remained in place.

In late 2004 the United Nations Human Rights Committee concluded a review on Poland's compliance with the International Covenant on Civil and Political Rights, demanding that the nation liberalize its abortion laws. In mid-2005 the leader of the ruling Democratic Left Alliance, Wojciech Olejniczak, spoke in favor of amendments to the abortion law, which would reduce the restrictions on a woman's right to choose. Olejniczak commented: "The Polish Left is not antireligious but I want to make one thing absolutely clear: the state must be secular" (BBC Monitoring Service, June 19, 2005).

Romania

During the rule of Communist dictator Nicolae Ceausescu (1967–89), abortion was allowed only when a woman was older than forty-five years and had at least five children. Modern contraception also was severely restricted. Ceausescu had hoped to build his country into a powerful nation based on population growth. Nonetheless, birth rates did not increase. Although the 1967–68 total fertility rate (3.6 lifetime births per woman) nearly doubled the 1966 level, it declined to 2.9 in 1970, fell to 2.1 by 1984, and remained at about 2.3 births per woman from 1985 through the end of Communism and Ceausescu's rule in 1989 ("World Fertility Report 2003," Population Division of the United Nations Department of Economic and Social Affairs, January 2005).

It was only after Ceausescu's regime was overthrown that the situation in Romania was revealed to the world. Without contraception, women resorted to abortion to prevent unwanted births. During Ceausescu's rule an estimated ten thousand women died from illegal abortions, either self-induced or induced by untrained persons. During the ten-year period prior to Ceausescu's fall from power (1979–89), Romania had the highest maternal mortality rate in Europe—ten times higher than any other European country (Patricia Stephenson, et al., "Commentary: The Public Health Consequences of Restricted Induced Abortion—Lessons from Romania," American Journal of Public Health, vol. 82, no. 10, October, 1992). Many women also suffered permanent disfigurement.

Romania's interim government after the revolution made abortion available on request through the twelfth week of pregnancy. Abortions up to the twenty-fourth week of pregnancy were permitted in cases of rape, incest, and endangerment of the woman's life if she were to carry her pregnancy to term. After abortion was legalized the total fertility rate declined from 2.3 live births to 1.5 live births per woman (1990–93), whereas the total induced abortion rates doubled, from 1.7 to 3.4 abortions per woman. Also, when abortion became legal in Romania in 1990, abortion-related mortality fell to one-third of its highest level, which had occurred the previous year ("Abortion in Context: United States and Worldwide: Issues in Brief," Alan Guttmacher Institute, 1999 Series, no. 1, May 1999).

With the shift in policy allowing abortion on demand, Romanians have resorted to abortion as a principal method of birth control. According to Glasgow's Sunday Herald, in 2002, 70% of pregnancies in Romania ended in abortion. In 2003 Romania had the second-highest abortion rate in Europe (after Russia), according to a February 10, 2004, news report by LifeSiteNews.com. In 2004, for the first time since the fall of the communist regime in 1989, the number of births was higher than the number of abortions (Iran Daily, May 3, 2005). The Romanian parliament passed a law in September 2004 guaranteeing women the right to be informed about abortions and their risks.

Russia

In 1970 Russia had 27.5 abortions for every ten live births; this ratio fell somewhat steadily to 17.5 abortions for every ten live births in 1997 (Julie DaVanzo and Clifford Grammich, Dire Demographics: Populations Trends in the Russian Federation, Santa Monica, CA: Rand, 2001). In October 2005 The Guardian, a London newspaper, reported that Russia still registered more abortions each year than live births.

Abortion law was liberalized in Russia in 1955. Abortions were allowed on demand through the twelfth week of pregnancy and for medical and social reasons through the twenty-second week. Because modern methods of contraception were not available for many years, most women relied on abortion to control childbirth. A Russian woman who did not want more than two children would likely have as many as four or more abortions in her lifetime.

However, in August 2003 the Russian government passed a resolution on abortion, which involves restrictions on women's access to abortion after twelve weeks. Previously, women in Russia could receive an abortion between twelve and twenty-two weeks of pregnancy by meeting one of thirteen special circumstances, including divorce, poverty, and poor housing. The 2003 resolution reduced these to four circumstances: rape, imprisonment, death or severe disability of the husband, or a court ruling removing the woman's parental rights.

In 2005 the Russian parliament (Duma) turned down proposed legislation that would further restrict the conditions under which a woman could obtain an abortion. Legislators declared that the proposed draft runs contrary to the fundamentals of the Russian legislation on protection of health of citizens, which gives a woman the right to decide on motherhood.

Ireland

Ireland is the only western European country that still bans abortion except in cases where the mother's life is threatened. (See Table 8.1.) (Northern Ireland's abortion laws differ; the section here does not address Northern Ireland.) In 1992 the Irish Supreme Court ruled that abortion could be legally performed if there was a threat to the mother's life, including the threat of suicide.

In late 1992 Irish voters approved a law giving women the right to obtain information regarding abortion services abroad and allowing women to travel abroad to get abortions. In May 1995 the Irish Supreme Court ruled constitutional a measure allowing doctors and clinics to provide women with information about foreign abortion clinics. In 1997 an Irish Times poll found that 77% of respondents believed abortion should be allowed.

According to the Irish Family Planning Association (http://www.ifpa.ie), slightly more than six thousand Irish women receive abortions annually at clinics in England, where the practice was legalized in 1967. Still more travel to the Netherlands, Spain, and Belgium for abortions. Although abortion is still illegal in Ireland, its abortion rate—as reported by the Irish Family Planning Association—was 7.5 in 2001 (abortions per one thousand women ages fifteen to forty-four).

China

In China abortion is permitted to save the mother's life, to preserve physical health, and to safeguard mental health. Abortion also is permitted in cases of rape, incest, and fetal impairment and for economic or social reasons.

In the 1970s China initiated a stringent family planning program that has resulted in one of the fastest fertility declines in the world. The program promotes one-child families in urban areas and two-child families in rural areas and for ethnic minorities. In "Low Fertility in Urban China," a conference paper presented to the International Union for the Scientific Study of Population (http://eprints.anu.edu.au/archive/00001368/, March 2001), Zhongwei Zhao notes that between 1975 and 1998 the total fertility rate declined by about two children, from 3.57 to 1.49 lifetime births per woman for China countrywide, and declined by about a half child in urban China, from 1.78 to 1.13. In 2005 China's total fertility rate remained low countrywide at 1.60 lifetime births per woman. Nonetheless, in 2005 China was the most populous country in the world with over 1.3 billion inhabitants ("2005 World Population Data Sheet," Population Reference Bureau, http://www.prb.org/pdf05/05WorldDataSheet_Eng.pdf, 2005).

Contraceptives generally are provided free by local family planning services, and the abortion-inducing drug mifepristone, approved in 1988, was used widely for more than a decade. However, in October 2001 the State Drug Administration reaffirmed a ban on unsupervised mifepristone use for abortions because of a rising black market for the drug and concerns that its unsupervised use could be dangerous. The pill cannot be sold at pharmacies, even with a prescription. It can only be given at a hospital under a doctor's supervision.

In some circumstances the government can mandate that an abortion be performed. In 1994 under the provisions of the Maternal Health Care Law, couples planning to marry had to submit to prenatal testing to prevent "inferior births." An abortion would be recommended if the fetus had a severe hereditary disease or was seriously impaired. Critics considered this a "eugenics law," designed to terminate the birth of defective babies.

China amended the law the following year, deleting the controversial language concerning "inferior births." A couple planning to get married was required to undergo a medical examination to determine the presence of genetic disorders. If such disorders were found, they had to agree to long-term contraception or they could not get married. Although the law specified that a woman carrying an imperfect fetus could not be coerced to abort, her physician must advise her to do so.

Critics feel that a pervading cultural preference for boys in China, coupled with the limitation on the number of births per family, endangers females. Every year, many girls are abandoned, killed, aborted, or hidden from family planning authorities.

The World Factbook 2005 (Dulles, VA: Potomac Books, 2005), a publication of the Central Intelligence Agency of the United States, estimates that in late 2005 106 boys were born for every one hundred girls worldwide. This statistic—the "sex ratio at birth"—indicates the number of male births for every one hundred female births. The World Factbook 2005 also estimates that, for China, the sex ratio at birth in late 2005 was 112 boys per one hundred girls. A July 2001 news release by the Population Council (http://www.popcouncil.org/mediacenter/newsreleases/pdr27_2chu.html) notes that the reported sex ratio at birth in China was about the same as the worldwide average in the 1960s and 1970s and that the ratio increased after 1980, from 108.5 in 1981 to 111.9 in 1990. The State Family Planning Commission has suggested that women with no or few sons were more likely to underreport female births and to practice selective abortion using ultrasound scans to determine the sex of their fetuses and ensure the birth of boys. Population data from the The World Factbook 2005 shows that in China men outnumber women by slightly over thirty-nine million.

India

When the Indian government started providing family planning services in 1952, it became the first developing country to promote population control. Overall, the total fertility rate in India has been declining. In 1981 the total fertility rate was 4.9 lifetime births per woman ("World Fertility Patterns 2004," United Nations Population Division). By 1990 the total fertility rate had decreased to 3.8, and by 2005 it was projected to be 2.8 (U.S. Census Bureau, "Global Population Profile: 2002," http://www.census.gov/ipc/www/wp02.html). Despite these efforts to control population growth, India has seen its population more than double between 1960 (446 million per the U.S. Census Bureau, "Global Population Profile: 2002") and mid-2005 (1.1 billion according to the "2005 World Population Data Sheet" published by the Population Reference Bureau). According to calculations of the Population Reference Bureau, India is expected to become more populous than China—the most populous country in 2005—by 2050.

In 1969 India legalized abortion to help control its population growth, but government facilities have not been able to keep up with the great number of women seeking abortions. In rural areas, where facilities are lacking or inadequate, women obtain abortions from midwives and untrained practitioners. Approximately twenty thousand Indian women die each year from unsafe abortions (Suneeta Mittal, Consortium on National Consensus for Medical Abortion in India, http://www.aiims.ac.in/aiims/events/Gynaewebsite/ma_finalsite/introduction.html). In 1995–96 an estimated 566,500 abortions were reported. (See Table 8.3.) The actual number, however, is believed to be higher.

There is a strong preference for sons in India, as in China. This preference in India is strongly influenced by the custom of providing a suitable dowry (money or property brought by a bride to her husband at marriage), which puts a great financial burden on the bride's parents. In addition, sons customarily live with their parents after marriage, providing both financial and emotional support to them, especially as the parents grow older.

Medical advances have made sex-selective abortions easier. Prenatal testing has become routine among educated middle- and upper-class women, who often terminate their pregnancies if they are carrying a daughter. Modern technology also has reached some rural areas, where vans with ultrasound machines enable expectant mothers to determine the sex of their fetuses. The enactment of laws in 1996 forbidding sex selection has not deterred selective abortion practices. After the 2001 census found that there were 927 females for every one thousand males younger than age six, the Indian Supreme Court in September 2003 ruled that federal and state governments must begin enforcing the ban on sex selection.

Latin America

In most countries of Latin America abortion is illegal except in cases of endangerment of the woman's life, rape, incest, and fetal abnormality. However, women rarely seek legal abortions using these "exceptions" because they do not know they are eligible nor do they know the legal requirements for obtaining an abortion. Hence, abortions have become secret and generally unsafe in Latin America.

According to the Center for Reproductive Rights, of the approximately twenty million unsafe abortions performed each year worldwide, an estimated four million—about one-fifth—are performed (illegally) in Latin America. Unsafe abortion is the cause of as many as 21% of maternal deaths—five thousand women each year—in Latin America ("Abortion in Context: United States and Worldwide: Issues in Brief," The Alan Guttmacher Institute, 1999).

According to the AGI, most of the women having an abortion in Latin America are in their twenties or older and married. Many already have children. Many married women, especially the poor, already have all the children they can afford to raise. Single women might not want to raise a child alone or cannot support a child by them-selves. Working women and those with more education may not want additional children. Some women continue to get pregnant because they are not using any contraception or because they are using unreliable methods, such as withdrawal. Others have unwanted pregnancies because they do not know about the likely time of conception or are using contraceptives incorrectly or irregularly.

MEXICO

As in the other Latin American countries, abortion is generally illegal in Mexico. However, abortions in this country are legal in some circumstances in all thirty-one states and the federal district; the law varies by state, however. All states allow abortion in cases of pregnancies resulting from rape. Most states and the federal district allow abortion if the pregnancy endangers the woman's life; in nine states and the federal district, abortion is legal if the woman's health is in serious danger.

The results of one study revealed that poverty was a key factor in leading Mexican women to seek unsafe abortions. Results of another study found that key reasons women sought induced abortions were that they became pregnant at a young age, their partner pressured them to do so, they had economic constraints, and they already had too many children (Davida Becker, Sandra G. Garcia, and Ulla Larsen, "Knowledge and Opinions about Abortion Law among Mexican Youth," International Family Planning Perspectives, vol. 28, no. 4, December 2002).

According to the AGI, 533,000 induced abortions occur each year in Mexico, which is 25.1 abortions per one thousand women ages fifteen to forty-nine and a ratio of 17.1 abortions per one hundred live births. More than 40% of women seeking abortions in Mexico are younger than age twenty-four, and 33% are older than age thirty.

Bureaucratic, legal, and medical barriers make it hard for Mexican women to obtain legal abortions. For instance, women seeking legal abortions in Mexico City in the case of rape face burdensome, time-consuming administrative procedures. Also, when a pregnancy threatens a woman's health in Mexico City, physicians are required to get a second opinion before authorizing an abortion. This process may cause a substantial delay; if this occurs, the abortion may be performed at a point in the pregnancy when it is less safe.

Provider attitudes and knowledge also affect women's ability to obtain legal abortion services. Conservative providers may refuse services and may treat poorly those women they suspect of having had induced abortions. Political and religious groups in Mexico create barriers to abortion services by trying to limit access and campaigning against efforts to liberalize abortion laws.

In September and October 2000 the Population Council's regional office for Latin America and the Caribbean, in collaboration with a Mexican market research firm, carried out a household survey in Mexico to gather information about the public's knowledge of and opinions on abortion and emergency contraception. Table 8.5 shows characteristics of the 907 respondents and their opinions about emergency contraception and abortion.

Most study participants (70-83%) felt that women should have access to legal abortion when a pregnancy is the result of a rape, when the woman's life is at risk, or when her health is in danger. All of the states from which study participants were selected permit abortion when a pregnancy results from rape, and 84% do so when a pregnancy poses a risk to a woman's life. (See Table 8.6.) A woman can obtain a legal abortion in 36% of states if a pregnancy is dangerous to her health or if the fetus is found to have severe birth defects.

Survey results released in 2005 revealed that poor Mexican youth ages thirteen to nineteen years had confusion about contraceptives and little understanding of their use. The survey, sponsored by a research center of the National Autonomous University of Mexico, showed that of the 15,488 participating teenagers, 12.9%, or close to two thousand, said that they had had sexual intercourse. Of those, fifty-seven said that their relations had resulted in an unwanted pregnancy, and 46.2% terminated the pregnancy with an abortion.

South Africa

In South Africa under apartheid (1948–91—the system of racial segregation that involved discrimination against nonwhites), abortion was illegal except in cases where the pregnancy threatened the woman's mental health. The government, fearing that black people would outnumber white people, used tax credits to encourage white women to have children. Nonetheless, many upper-and middle-income women with unwanted pregnancies sought abortions in private physicians' offices or abroad. Many poor women with unwanted pregnancies, however, either terminated their own pregnancies or used the services of unqualified abortionists.

In 1975, reacting to pressures from the medical profession and women's groups, the legislature enacted the Abortion and Sterilization Act, which legalized abortion. Nonetheless, because of the stringent provisions of the law, such as requiring the approval of two physicians and a psychiatrist, many women continued seeking illegal abortions.

In November 1996 South Africa's first democratically elected Parliament passed a new abortion law—the most liberal abortion law in Africa—The Choice of Termination of Pregnancy Act. Under the law, women and adolescents could get state funding for abortions up to the twelfth week of pregnancy. From the thirteenth up to and including the twentieth week of pregnancy, abortion is legal in cases of danger to the mother's physical or mental health, rape, incest, and fetal defect. The law also allows abortion if continuing the pregnancy would affect the woman's social or economic circumstances. Abortion after twenty weeks of pregnancy also is allowed if a physician or trained midwife finds that continuation of the pregnancy would threaten the woman's health or result in fetal abnormality. Although adolescents are counseled to consult their parents, the law allows them to have an abortion without parental knowledge. Research after the implementation of the new abortion law suggests that the act has increased availability, but access to an abortion is still elusive for certain groups, especially women from rural areas and younger women.

In mid-2005 Parliament put forth an amendment to the 1996 law—The Choice of Termination of Pregnancy Amendment Bill. This proposed legislation sought to designate facilities that can provide abortion services to women, decentralize and improve the efficiency of the abortion process, and allow registered nurses and midwives who have undergone appropriate training to perform abortions. However, the bill encountered a massive groundswell of public opinion against abortion, which became evident after the 1996 legislation went into effect.

In an effort to quantify public sentiment on this issue, the Human Sciences Research Council questioned 4,980 adults in the South African Social Attitudes Survey. Results of the survey were released in full in 2004 and revealed two key findings. One was that more than two-thirds (70%) of the South African adult respondents were opposed to abortion, even if the family concerned is poor and cannot afford more children. The other key finding was that more than half (56%) were against ending the pregnancy of a woman whose child may be "deformed."

CROSS-BORDER ABORTIONS

Abortion laws in Europe run the gamut from a total ban in Ireland (see the subheading "Ireland") to the twenty-four-week gestation limit in Great Britain and the Netherlands. Women who wish to terminate an early pregnancy can travel to countries such as France, Great Britain, and Sweden and have a medical abortion with the help of the abortion-inducing pill mifepristone. As expected, women of means are more able to avoid their country's abortion laws by going to a country that suits their situation. According to Heather Boonstra in "Voi-cing Concern for Women, Abortion Foes Seek Limits on Availability of Mifepristone" (The Guttmacher Report on Public Policy, vol. 4, no. 2, April 2001), abortion rates declined in the 1990s in countries that approved mife-pristone. (See Table 8.7 and Figure 8.2.)

DEATHS FROM ABORTION

Abortion is one of the safest medical procedures. As with most medical procedures, however, it becomes unsafe if it is performed by untrained providers in unsanitary conditions. For many women with unwanted pregnancies, a safe abortion can be too expensive, unavailable, or illegal. Because of these limitations, a woman may delay getting an abortion until later in her pregnancy when the risk of complications increases.

WHO estimated that in 2000 approximately 67,900 women worldwide died due to unsafe abortions. (See Table 8.8.) This accounts for 13% of maternal deaths worldwide. Most deaths due to unsafe abortions occur in the developing world. It is primarily these countries in which abortion is illegal, and thus women there have the majority of the illegal, generally unsafe abortions that occur worldwide each year. For example, according to the WHO, 140 women died due to unsafe abortions per one hundred thousand live births in 2000 in eastern Africa compared to less than one death per one hundred thousand live births due to unsafe abortions in eastern Asia, northern Europe, western Europe, and northern America.

Up to half of all women who undergo unsafe abortions have complications. The most common complications include incomplete abortion, tears in the cervix, perforation of the uterus, fever, infection, septic shock, and severe hemorrhaging. Other serious long-term health consequences also may affect women who have unsafe abortions. These problems may include chronic pelvic pain, problems getting and staying pregnant, infertility, blockage of a fallopian tube, and ectopic pregnancy.

A WORLDWIDE PLAN FOR REPRODUCTIVE HEALTH

At the landmark International Conference on Population and Development (ICPD) in Cairo, Egypt, in September 1994, 179 nations reached consensus on a twenty-year plan to achieve "reproductive health and rights for all." The plan was wide-ranging and included ideas about increased contraceptive services, fewer maternal deaths, better education for girls, and greater equality for women. The Cairo conference was the first in which the pervasiveness of abortions throughout the world was discussed openly.

The international community agreed on a common position regarding abortion (quoted in "Background Information on Key International Agreements," UNFPA: United Nations Population Fund, http://www.unfpa.org/mothers/concensus.htm), which states:

In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women's health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family planning services. Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counseling.

In July 1999 179 countries met to assess the progress of the "Programme of Action." The five-year review process, known as ICPD+5, found that nations implementing the Programme recommendations had improved conditions in their countries. For example, more than forty countries had introduced reproductive health services, and nearly half the countries had addressed the issue of adolescent reproductive health needs. Almost all Latin American countries had introduced policies or laws to safeguard women's rights, and more than half the Asian countries and some African countries had protected women's rights in such areas as inheritance, property, and employment. Nonetheless, the delegates agreed that much work still needed to be done.

In 2004 a ten-year review of the Programme of Action took place. Progress toward goals was seen to be impressive; however, there was also mixed results. For example, although the United Nations Population Fund (UNFPA) reported that contraceptive use had increased by 11% since 1994, nevertheless, birth rates remained high in some parts of the world, particularly sub-Saharan Africa and parts of Asia. (A high birth rate is often due to a lack of affordable contraception.) In another example, although only twenty-four deaths occur per one hundred thousand live births in Europe, nevertheless, 920 women die for every one hundred thousand live births in sub-Saharan Africa. Despite these setbacks, the attendees at the ICPD+10 meetings declared the need to continue addressing major issues such as gender equality, reproductive health and family planning, safe motherhood, and safe abortion.