legalization of abortion research paper

What can economic research tell us about the effect of abortion access on women’s lives?

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November 30, 2021

21 min read

On September 20, 2021, a group of 154 distinguished economists and researchers filed an amicus brief to the Supreme Court of the United States in advance of the Mississippi case, Dobbs v. Jackson Women’s Health Organization . For a full review of the evidence that shows how causal inference tools have been used to measure the effects of abortion access in the U.S., read the brief here .

Introduction

Dobbs v. Jackson Women’s Health Organization considers the constitutionality of a 2018 Mississippi law that prohibits women from accessing abortions after 15 weeks of pregnancy. This case is widely expected to determine the fate of Roe v. Wade as Mississippi is directly challenging the precedent set by the Supreme Court’s decisions in Roe , which protects abortion access before fetal viability (typically between 24 and 28 weeks of pregnancy). On December 1, 2021, the Supreme Court will hear oral arguments in Dobbs v. Jackson . In asking the Court to overturn Roe , the state of Mississippi offers reassurances that “there is simply no causal link between the availability of abortion and the capacity of women to act in society” 1 and hence no reason to believe that abortion access has shaped “the ability of women to participate equally in the economic and social life of the Nation” 2 as the Court had previously held.

While the debate over abortion often centers on largely intractable subjective questions of ethics and morality, in this instance the Court is being asked to consider an objective question about the causal effects of abortion access on the lives of women and their families. The field of economics affords insights into these objective questions through the application of sophisticated methodological approaches that can be used to isolate and measure the causal effects of abortion access on reproductive, social, and economic outcomes for women and their families.

Separating Correlation from Causation: The “Credibility Revolution” in Economics

To measure the causal effect of abortion on women’s lives, one must differentiate its effects from those of other forces, such as economic opportunity, social mores, the availability of contraception. Powerful statistical methodologies in the causal inference toolbox have made it possible for economists to do just that, moving beyond the maxim “correlation isn’t necessarily causation” and applying the scientific method to figure out when it is.

This year’s decision by the Economic Sciences Prize Committee recognized the contributions 3 of economists David Card, Joshua Angrist, and Guido Imbens, awarding them the Nobel Prize for their pathbreaking work developing and applying the tools of causal inference in a movement dubbed “the credibility revolution” (Angrist and Pischke, 2010). The gold standard for establishing such credibility is a well-executed randomized controlled trial – an experiment conducted in the lab or field in which treatment is randomly assigned. When economists can feasibly and ethically implement such experiments, they do. However, in the social world, this opportunity is often not available. For instance, one cannot feasibly or ethically randomly assign abortion access to some individuals but not others. Faced with this obstacle, economists turn to “natural” or “quasi” experimental methods, ones in which they are able to credibly argue that treatment is as good as randomly assigned.

The Effects of Abortion Access on Women’s Reproductive, Economic, and Social Lives

Evidence of the effects of abortion legalization.

The history of abortion legalization in the United States affords both a canonical and salient example of a natural experiment. While Roe v. Wade legalized abortion in most of the country in 1973, five states—Alaska, California, Hawaii, New York, and Washington—and the District of Columbia repealed their abortion bans several years in advance of Roe . Using a methodology known as “difference-in-difference estimation,” researchers compared changes in outcomes in these “repeal states” when they lifted abortion bans to changes in outcomes in the rest of the country. They also compared changes in outcomes in the rest of the country in 1973 when Roe legalized abortion to changes in outcomes in the repeal states where abortion already was legal. This difference-in-differences methodology allows the states where abortion access is not changing to serve as a counterfactual or “control” group that accounts for other forces that were impacting fertility and women’s lives in the Roe era.

Among the first to employ this approach was a team of economists (Levine, Staiger, Kane, and Zimmerman, 1999) who estimated that the legalization of abortion in repeal states led to a 4% to 11% decline in births in those states relative to the rest of the country. Levine and his co-authors found that these fertility effects were particularly large for teens and women of color, who experienced birth rate reductions that were nearly three times greater than the overall population as a result of abortion legalization. Multiple research teams have replicated the essential finding that abortion legalization substantially impacted American fertility while extending the analysis to consider other outcomes. 4 For example, Myers (2017) found that abortion legalization reduced the number of women who became teen mothers by 34% and the number who became teen brides by 20%, and again observed effects that were even larger for Black teens. Farin, Hoehn-Velasco, and Pesko (2021) found that abortion legalization reduced maternal mortality among Black women by 30-40%, with little impact on white women, offering the explanation that where abortion was illegal, Black women were less likely to be able to access safe abortions by traveling to other states or countries or by obtaining a clandestine abortion from a trusted health care provider.

The ripple effects of abortion access on the lives of women and their families

This research, which clearly demonstrates the causal relationship between abortion access and first-order demographic and health outcomes, laid the foundation for researchers to measure further ripple effects through the lives of women and their families. Multiple teams of authors have extended the difference-in-differences research designs to study educational and labor market outcomes, finding that abortion legalization increased women’s education, labor force participation, occupational prestige, and earnings and that all these effects were particularly large for Black women (Angrist and Evans, 1996; Kalist, 2004; Lindo, Pineda-Torres, Pritchard, and Tajali, 2020; Jones, 2021).

Additionally, research shows that abortion access has not only had profound effects on women’s economic and social lives but has also impacted the circumstances into which children are born. Researchers using difference-in-differences research designs have found that abortion legalization reduced the number of children who were unwanted (Bitler and Zavodny, 2002a, reduced cases of child neglect and abuse (Bitler and Zavodny, 2002b; 2004), reduced the number of children who lived in poverty (Gruber, Levine, and Staiger, 1999), and improved long-run outcomes of an entire generation of children by increasing the likelihood of attending college and reducing the likelihood of living in poverty and receiving public assistance (Ananat, Gruber, Levine, and Staiger, 2009).

Access to abortion continues to be important to women’s lives

The research cited above relies on variation in abortion access from the 1970s, and much has changed in terms of both reproductive technologies and women’s lives. Recent research shows, however, that even with the social, economic, and legal shifts that have occurred over the last few decades and even with expanded access to contraception, abortion access remains relevant to women’s reproductive lives. Today, nearly half of pregnancies are unintended (Finer and Zolna, 2016). About 6% of young women (ages 15-34) experience an unintended pregnancy each year (Finer, Lindberg, and Desai, 2018), and about 1.4% of women of childbearing age obtain an abortion each year (Jones, Witwer, and Jerman, 2019). At these rates, approximately one in four women will receive an abortion in their reproductive lifetimes. The fact is clear: women continue to rely on abortion access to determine their reproductive lives.

But what about their economic and social lives? While women have made great progress in terms of their educational attainment, career trajectories, and role in society, mothers face a variety of challenges and penalties that are not adequately addressed by public policy. Following the birth of a child, it’s well documented that working mothers face a “motherhood wage penalty,” which entails lower wages than women who did not have a child (Waldfogel, 1998; Anderson, Binder, and Krause, 2002; Kelven et al., 2019). Maternity leave may combat this penalty as it allows women to return to their jobs following the birth of a child – encouraging them to remain attached to the labor force (Rossin-Slater, 2017). However, as of this writing, the U.S. only offers up to 12 weeks of unpaid leave through the FMLA, which extends coverage to less than 60% of all workers. 5 And even if a mother is able to return to work, childcare in the U.S. is costly and often inaccessible for many. Families with infants can be expected to pay around $11,000 a year for childcare and subsidies are only available for 1 in 6 children that are eligible under the federal program. 6 Without a federal paid leave policy and access to affordable childcare, the U.S. lacks the infrastructure to adequately support mothers, and especially working mothers – making the prospect of motherhood financially unworkable for some.

This is relevant when considering that the women who seek abortions tend to be low-income mothers experiencing disruptive life events. In the most recent survey of abortion patients conducted by the Guttmacher Institute, 97% are adults, 49% are living below the poverty line, 59% already have children, and 55% are experiencing a disruptive life event such as losing a job, breaking up with a partner, or falling behind on rent (Jones and Jerman, 2017a and 2017b). It is not a stretch to imagine that access to abortion could be pivotal to these women’s financial lives, and recent evidence from “The Turnaway Study” 7 provides empirical support for this supposition. In this study, an interdisciplinary team of researchers follows two groups of women who were typically seeking abortions in the second trimester: one group that arrived at abortion clinics and learned they were just over the gestational age threshold for abortions and were “turned away” and a second that was just under the threshold and were provided an abortion. Miller, Wherry, and Foster (2020) match individuals in both groups to their Experian credit reports and observe that in the months leading up to the moment they sought an abortion, financial outcomes for both groups were trending similarly. At the moment one group is turned away from a wanted abortion, however, they began to experience substantial financial distress, exhibiting a 78% increase in past-due debt and an 81% increase in public records related to bankruptcies, evictions, and court judgments.

If Roe were overturned, the number of women experiencing substantial obstacles to obtaining an abortion would dramatically increase.

If Roe were overturned, the number of women experiencing substantial obstacles to obtaining an abortion would dramatically increase. Twelve states have enacted “trigger bans” designed to outlaw abortion in the immediate aftermath of a Roe reversal, while an additional 10 are considered highly likely to quickly enact new bans. 8 These bans would shutter abortion facilities across a wide swath of the American south and midwest, dramatically increasing travel distances and the logistical costs of obtaining an abortion. Economics research predicts what is likely to happen next. Multiple teams of economists have exploited natural experiments arising from mandatory waiting periods (Joyce and Kaestner, 2001; Lindo and Pineda-Torres, 2021; Myers, 2021) and provider closures (Quast, Gonzalez, and Ziemba, 2017; Fischer, Royer, and White, 2018; Lindo, Myers, Schlosser, and Cunningham, 2020; Venator and Fletcher, 2021; Myers, 2021). All have found that increases in travel distances prevent large numbers of women seeking abortions from reaching a provider and that most of these women give birth as a result. For instance, Lindo and co-authors (2020) exploit a natural experiment arising from the sudden closure of half of Texas’s abortion clinics in 2013 and find that an increase in travel distance from 0 to 100 miles results in a 25.8% decrease in abortions. Myers, Jones, and Upadhyay (2019) use these results to envision a post- Roe United States, forecasting that if Roe is overturned and the expected states begin to ban abortions, approximately 1/3 of women living in affected regions would be unable to reach an abortion provider, amounting to roughly 100,000 women in the first year alone.

Restricting, or outright eliminating, abortion access by overturning Roe v. Wade would diminish women’s personal and economic lives, as well as the lives of their families.

Whether one’s stance on abortion access is driven by deeply held views on women’s bodily autonomy or when life begins, the decades of research using rigorous methods is clear: there is a causal link between access to abortion and whether, when, and under what circumstances women become mothers, with ripple effects throughout their lives. Access affects their education, earnings, careers, and the subsequent life outcomes for their children. In the state’s argument, Mississippi rejects the causal link between access to abortion and societal outcomes established by economists and states that the availability of abortion isn’t relevant to women’s full participation in society. Economists provide clear evidence that overturning Roe would prevent large numbers of women experiencing unintended pregnancies—many of whom are low-income and financially vulnerable mothers—from obtaining desired abortions. Restricting, or outright eliminating, that access by overturning Roe v. Wade would diminish women’s personal and economic lives, as well as the lives of their families.

Caitlin Knowles Myers did not receive financial support from any firm or person for this article. She has received financial compensation from Planned Parenthood Federation of America and the Center for Reproductive Rights for serving as an expert witness in litigation involving abortion regulations. She has not and will not receive financial compensation for her role in the amicus brief described here. Other than the aforementioned, she has not received financial support from any firm or person with a financial or political interest in this article. Caitlin Knowles Myers is not currently an officer, director, or board member of any organization with a financial or political interest in this article.

Abboud, Ali, 2019. “The Impact of Early Fertility Shocks on Women’s Fertility and Labor Market Outcomes.” Available from SSRN: https://ssrn.com/abstract=3512913

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Bitler, Marianne, and Madeline Zavodny, 2002b. “Child Abuse and Abortion Availability.” American Economic Review , 92 (2): 363-367. Retrieved from https://www.aeaweb.org/articles?id=10.1257/000282802320191624

Bitler, Marianne, and Madeline Zavodny, 2004. “Child Maltreatment, Abortion Availability, and Economic Conditions.” Review of Economics of the Household 2: 119-141. Retrieved from https://doi.org/10.1023/B:REHO.0000031610.36468.0e

Farin, Sherajum Monira, Hoehn-Velasco, Lauren, and Michael Pesko, 2021. “The Impact of Legal Abortion on Maternal Health: Looking to the Past to Inform the Present.” Retrieved from SSRN: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3913899

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Fischer, Stefanie, Royer, Heather, and Corey White, 2017. “The Impacts of Reduced Access to Abortion and Family Planning Services on Abortion, Births, and Contraceptive Purchases.” National Bureau of Economic Research Working Paper 23634 . Retrieved from https://www.nber.org/papers/w23634

Gruber, Jonathan, Levine, Phillip, and Douglas Staiger, 1999. “Abortion Legalization and Child Living Circumstances: Who Is the ‘Marginal Child’?” Quarterly Journal of Economics 114. Retrieved from https://doi.org/10.1162/003355399556007

Guldi, Melanie, 2008. “Fertility effects of abortion and birth control pill access for minors.” Demography 45 . Retrieved from https://doi.org/10.1353/dem.0.0026

Hoynes, Hilary, Schanzenbach, Diane Whitmore, and Douglas Almond, 2016. “Long-Run Impacts of Childhood Access to the Safety Net.” American Economic Review 106(4). Retrieved from https://www.aeaweb.org/articles?id=10.1257/aer.20130375

Jones, Kelly, 2021. “At a Crossroads: The Impact of Abortion Access on Future Economic Outcomes.” American University Working Paper . Retrieved from https://doi.org/10.17606/0Q51-0R11 .

Jones, Rachel K., Witwer, Elizabeth, Jerman, Jenna, September 18, 2018. “Abortion Incidence and Service Availability in the United States, 2017.” Guttmacher Institute. Retrieved from https://www.guttmacher.org/sites/ default/files/report_pdf/abortion-inciden ce-service-availability-us-2017.

Jones Rachel K., and Janna Jerman, 2017a. ”Population group abortion rates and lifetime incidence of abortion: United States, 2008–2014.” American Journal of Public Health 107 (12). Retrieved from https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2017.304042

Jones, Rachel K. and Jenna Jerman, 2017b. “Characteristics and Circumstances of U.S. Women Who Obtain Very Early and Second-Trimester Abortions.” PLoS One . Retrieved from https://pubmed.ncbi.nlm.nih.gov/28121999/

Joyce, Ted, and Robert Kaestner, 2001. “The Impact of Mandatory Waiting Periods and Parental Consent Laws on the Timing of Abortion and State of Occurrence among Adolescents in Mississippi and South Carolina.” Journal of Policy Analysis and Management 20(2) . Retrieved from https://www.jstor.org/stable/3325799 .

Kalist, David E., 2004. “Abortion and Female Labor Force Participation: Evidence Prior to Roe v. Wade.” Journal of Labor Research 25 (3) .

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Kleven, Henrik, Landais, Camille, Posch, Johanna, Steinhauer, Andreas, and Josef Zweimuleler, 2019. “Child Penalties Across Countries: Evidence and Explanations.” AEA Papers and Proceedings 109. Retrieved from https://www.aeaweb.org/articles?id=10.1257/pandp.20191078/

Levine, Phillip, Staiger, Douglas, Kane, Thomas, and David Zimmerman, 1999. “Roe v. Wade and American Fertility.” American Journal Of Public Health 89(2) . Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1508542/

Lindo, Jason M., Myers, Caitlin Knowles, Schlosser, Andrea, and Scott Cunningham, 2020. “How Far Is Too Far? New Evidence on Abortion Clinic Closures, Access, and Abortions” Journal of Human Resources 55. Retrieved from http://jhr.uwpress.org/content/55/4/1137.refs

Lindo, Jason M., Pineda-Torres, Mayra, Pritchard, David, and Hedieh Tajali, 2020. “Legal Access to Reproductive Control Technology, Women’s Education, and Earnings Approaching Retirement.” AEA Papers and Proceedings 110. Retrieved from https://www.aeaweb.org/articles?id=10.1257/pandp.20201108

Lindo, Jason M., and Mayra Pineda-Torres, 2021. “New Evidence on the Effects of Mandatory Waiting Periods for Abortion.” J ournal of Health Econ omics. Retrieved from https://pubmed.ncbi.nlm.nih.gov/34607119/

Miguel, Edward, Satyanath, Shanker, and Ernest Sergenti, 2004. “Economic Shocks and Civil Conflict: An Instrumental Variables Approach.” Journal of Political Economy 112(4). Retrieved from https://www.jstor.org/stable/10.1086/421174

Miller, Sarah, Wherry, Laura R., and Diana Greene Foster, 2020. “The Economic Consequences of Being Denied an Abortion.” National Bureau of Economic Research, Working Paper 26662 . Retrieved from https://www.nber.org/papers/w26662 .

Myers, Caitlin Knowles, 2017. “The Power of Abortion Policy: Reexamining the Effects of Young Women’s Access to Reproductive Control” Journal of Political Economy 125(6) . Retrieved from https://doi.org/10.1086/694293 .

Myers, Caitlin Knowles, Jones, Rachel, and Ushma Upadhyay, 2019. “Predicted changes in abortion access and incidence in a post-Roe world.” Contraception 100(5). Retrieved from https://pubmed.ncbi.nlm.nih.gov/31376381/

Myers, Caitlin Knowles, 2021. “Cooling off or Burdened? The Effects of Mandatory Waiting Periods on Abortions and Births.” IZA Institute of Labor Economics No. 14434. Retrieved from https://www.iza.org/publications/dp/14434/cooling-off-or-burdened-the-effects-of-mandatory-waiting-periods-on-abortions-and-births

Quast, Troy, Gonzalez, Fidel, and Robert Ziemba, 2017. “Abortion Facility Closings and Abortion Rates in Texas.” Inquiry: A Journal of Medical Care Organization, Provision and Financing 54 . Retrieved from https://journals.sagepub.com/doi/full/10.1177/0046958017700944

Rossin-Slater, Maya, 2017. “Maternity and Family Leave Policy.” National Bureau of Economic Research Working Paper 23069. Retrieved from https://www.nber.org/papers/w23069

Venator, Joanna, and Jason Fletcher, 2020. “Undue Burden Beyond Texas: An Analysis of Abortion Clinic Closures, Births, and Abortions in Wisconsin.” Journal of Policy Analysis and Management 40(3). Retrieved from https://doi.org/10.1002/pam.22263

Waldfogel, Jane, 1998. “The family gap for young women in the United States and Britain: Can maternity leave make a difference?” Journal of Labor Economics 16(3).

Thomas E. Dobbs v. Jackson Women’s Health Organization. On Writ of Certiorari to the United States Court of Appeals for the Fifth Circuit, Brief in Support of Petitioners, No. 19-1392.
Thomas E. Dobbs v. Jackson Women’s Health Organization. On Writ of Certiorari to the United States Court of Appeals for the Fifth Circuit, Brief for Petitioners, No. 19-139, Retrieved from https://www.supremecourt.gov/DocketPDF/19/19-1392/184703/20210722161332385_19-1392BriefForPetitioners.pdf
The Nobel Prize. 2021. “Press release: The Prize in Economic Sciences 202.” Retrieved from https://www.nobelprize.org/prizes/economic-sciences/2021/press-release/
See Angrist and Evans (1996), Gruber et al. (1999), Ananat et al. (2009), Guldi (2008), Myers (2017), Abboud (2019), Jones (2021).
Brown, Scott, Herr, Jane, Roy, Radha , and Jacob Alex Klerman, July 2020. “Employee and Worksite Perspectives of the FMLA Who Is Eligible?” U.S. Department of Labor. Retrieved from https://www.dol.gov/sites/dolgov/files/OASP/evaluation/pdf/WHD_FMLA2018PB1WhoIsEligible_StudyBrief_Aug2020.pdf
Whitehurst, Grover J., April 19, 2018. “What is the market price of daycare and preschool?” Brookings Institution. Retrieved from https://www.brookings.edu/research/what-is-the-market-price-of-daycare-and-preschool/; Chien, Nina, 2021. “Factsheet: Estimates of Child Care Eligibility & Receipt for Fiscal Year 2018.” U.S. Department of Health and Human Services. Retrieved from https://aspe.hhs.gov/sites/default/files/20 21-08/cy-2018-child-care-subsidy-eligibility.pdf
Advancing New Standards in Reproductive Health (NSIRH). “The Turnaway Study.” Retrieved from https://www.ansirh.org/research/ongoing/turnaway-study.
Center for Reproductive Rights, 2021. “What If Roe Fell?” Retrieved from https://maps.reproductiverights.org/what-if-roe-fell

Economic Studies

Center for Economic Security and Opportunity

Michael Hais, Morley Winograd

August 16, 2024

E.J. Dionne, Jr., Elaine Kamarck, Kathryn Dunn Tenpas

August 15, 2024

Jonathan Rauch, Kathryn Dunn Tenpas, Vanessa Williamson

Open access
Published: 28 June 2021

Impact of abortion law reforms on women’s health services and outcomes: a systematic review protocol

Foluso Ishola ORCID: orcid.org/0000-0002-8644-0570 1 ,
U. Vivian Ukah 1 &
Arijit Nandi 1

Systematic Reviews volume 10 , Article number: 192 ( 2021 ) Cite this article

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A country’s abortion law is a key component in determining the enabling environment for safe abortion. While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, with the majority of them moving away from an absolute ban. However, the implications of these reforms on women’s access to and use of health services, as well as their health outcomes, is uncertain. First, there are methodological challenges to the evaluation of abortion laws, since these changes are not exogenous. Second, extant evaluations may be limited in terms of their generalizability, given variation in reforms across the abortion legality spectrum and differences in levels of implementation and enforcement cross-nationally. This systematic review aims to address this gap. Our aim is to systematically collect, evaluate, and synthesize empirical research evidence concerning the impact of abortion law reforms on women’s health services and outcomes in LMICs.

We will conduct a systematic review of the peer-reviewed literature on changes in abortion laws and women’s health services and outcomes in LMICs. We will search Medline, Embase, CINAHL, and Web of Science databases, as well as grey literature and reference lists of included studies for further relevant literature. As our goal is to draw inference on the impact of abortion law reforms, we will include quasi-experimental studies examining the impact of change in abortion laws on at least one of our outcomes of interest. We will assess the methodological quality of studies using the quasi-experimental study designs series checklist. Due to anticipated heterogeneity in policy changes, outcomes, and study designs, we will synthesize results through a narrative description.

This review will systematically appraise and synthesize the research evidence on the impact of abortion law reforms on women’s health services and outcomes in LMICs. We will examine the effect of legislative reforms and investigate the conditions that might contribute to heterogeneous effects, including whether specific groups of women are differentially affected by abortion law reforms. We will discuss gaps and future directions for research. Findings from this review could provide evidence on emerging strategies to influence policy reforms, implement abortion services and scale up accessibility.

Systematic review registration

PROSPERO CRD42019126927

Peer Review reports

An estimated 25·1 million unsafe abortions occur each year, with 97% of these in developing countries [ 1 , 2 , 3 ]. Despite its frequency, unsafe abortion remains a major global public health challenge [ 4 , 5 ]. According to the World health Organization (WHO), nearly 8% of maternal deaths were attributed to unsafe abortion, with the majority of these occurring in developing countries [ 5 , 6 ]. Approximately 7 million women are admitted to hospitals every year due to complications from unsafe abortion such as hemorrhage, infections, septic shock, uterine and intestinal perforation, and peritonitis [ 7 , 8 , 9 ]. These often result in long-term effects such as infertility and chronic reproductive tract infections. The annual cost of treating major complications from unsafe abortion is estimated at US$ 232 million each year in developing countries [ 10 , 11 ]. The negative consequences on children’s health, well-being, and development have also been documented. Unsafe abortion increases risk of poor birth outcomes, neonatal and infant mortality [ 12 , 13 ]. Additionally, women who lack access to safe and legal abortion are often forced to continue with unwanted pregnancies, and may not seek prenatal care [ 14 ], which might increase risks of child morbidity and mortality.

Access to safe abortion services is often limited due to a wide range of barriers. Collectively, these barriers contribute to the staggering number of deaths and disabilities seen annually as a result of unsafe abortion, which are disproportionately felt in developing countries [ 15 , 16 , 17 ]. A recent systematic review on the barriers to abortion access in low- and middle-income countries (LMICs) implicated the following factors: restrictive abortion laws, lack of knowledge about abortion law or locations that provide abortion, high cost of services, judgmental provider attitudes, scarcity of facilities and medical equipment, poor training and shortage of staff, stigma on social and religious grounds, and lack of decision making power [ 17 ].

An important factor regulating access to abortion is abortion law [ 17 , 18 , 19 ]. Although abortion is a medical procedure, its legal status in many countries has been incorporated in penal codes which specify grounds in which abortion is permitted. These include prohibition in all circumstances, to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, and on request with no requirement for justification [ 18 , 19 , 20 ].

Although abortion laws in different countries are usually compared based on the grounds under which legal abortions are allowed, these comparisons rarely take into account components of the legal framework that may have strongly restrictive implications, such as regulation of facilities that are authorized to provide abortions, mandatory waiting periods, reporting requirements in cases of rape, limited choice in terms of the method of abortion, and requirements for third-party authorizations [ 19 , 21 , 22 ]. For example, the Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds. It is considered liberal, as it permits legal abortions for more indications than most countries in Sub-Saharan Africa; however, abortions must only be provided in registered hospitals, and three medical doctors—one of whom must be a specialist—must provide signatures to allow the procedure to take place [ 22 ]. Given the critical shortage of doctors in Zambia [ 23 ], this is in fact a major restriction that is only captured by a thorough analysis of the conditions under which abortion services are provided.

Additionally, abortion laws may exist outside the penal codes in some countries, where they are supplemented by health legislation and regulations such as public health statutes, reproductive health acts, court decisions, medical ethic codes, practice guidelines, and general health acts [ 18 , 19 , 24 ]. The diversity of regulatory documents may lead to conflicting directives about the grounds under which abortion is lawful [ 19 ]. For example, in Kenya and Uganda, standards and guidelines on the reduction of morbidity and mortality due to unsafe abortion supported by the constitution was contradictory to the penal code, leaving room for an ambiguous interpretation of the legal environment [ 25 ].

Regulations restricting the range of abortion methods from which women can choose, including medication abortion in particular, may also affect abortion access [ 26 , 27 ]. A literature review contextualizing medication abortion in seven African countries reported that incidence of medication abortion is low despite being a safe, effective, and low-cost abortion method, likely due to legal restrictions on access to the medications [ 27 ].

Over the past two decades, many LMICs have reformed their abortion laws [ 3 , 28 ]. Most have expanded the grounds on which abortion may be performed legally, while very few have restricted access. Countries like Uruguay, South Africa, and Portugal have amended their laws to allow abortion on request in the first trimester of pregnancy [ 29 , 30 ]. Conversely, in Nicaragua, a law to ban all abortion without any exception was introduced in 2006 [ 31 ].

Progressive reforms are expected to lead to improvements in women’s access to safe abortion and health outcomes, including reductions in the death and disabilities that accompany unsafe abortion, and reductions in stigma over the longer term [ 17 , 29 , 32 ]. However, abortion law reforms may yield different outcomes even in countries that experience similar reforms, as the legislative processes that are associated with changing abortion laws take place in highly distinct political, economic, religious, and social contexts [ 28 , 33 ]. This variation may contribute to abortion law reforms having different effects with respect to the health services and outcomes that they are hypothesized to influence [ 17 , 29 ].

Extant empirical literature has examined changes in abortion-related morbidity and mortality, contraceptive usage, fertility, and other health-related outcomes following reforms to abortion laws [ 34 , 35 , 36 , 37 ]. For example, a study in Mexico reported that a policy that decriminalized and subsidized early-term elective abortion led to substantial reductions in maternal morbidity and that this was particularly strong among vulnerable populations such as young and socioeconomically disadvantaged women [ 38 ].

To the best of our knowledge, however, the growing literature on the impact of abortion law reforms on women’s health services and outcomes has not been systematically reviewed. A study by Benson et al. evaluated evidence on the impact of abortion policy reforms on maternal death in three countries, Romania, South Africa, and Bangladesh, where reforms were immediately followed by strategies to implement abortion services, scale up accessibility, and establish complementary reproductive and maternal health services [ 39 ]. The three countries highlighted in this paper provided unique insights into implementation and practical application following law reforms, in spite of limited resources. However, the review focused only on a selection of countries that have enacted similar reforms and it is unclear if its conclusions are more widely generalizable.

Accordingly, the primary objective of this review is to summarize studies that have estimated the causal effect of a change in abortion law on women’s health services and outcomes. Additionally, we aim to examine heterogeneity in the impacts of abortion reforms, including variation across specific population sub-groups and contexts (e.g., due to variations in the intensity of enforcement and service delivery). Through this review, we aim to offer a higher-level view of the impact of abortion law reforms in LMICs, beyond what can be gained from any individual study, and to thereby highlight patterns in the evidence across studies, gaps in current research, and to identify promising programs and strategies that could be adapted and applied more broadly to increase access to safe abortion services.

The review protocol has been reported using Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines [ 40 ] (Additional file 1 ). It was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database CRD42019126927.

Eligibility criteria

Types of studies.

This review will consider quasi-experimental studies which aim to estimate the causal effect of a change in a specific law or reform and an outcome, but in which participants (in this case jurisdictions, whether countries, states/provinces, or smaller units) are not randomly assigned to treatment conditions [ 41 ]. Eligible designs include the following:

Pretest-posttest designs where the outcome is compared before and after the reform, as well as nonequivalent groups designs, such as pretest-posttest design that includes a comparison group, also known as a controlled before and after (CBA) designs.

Interrupted time series (ITS) designs where the trend of an outcome after an abortion law reform is compared to a counterfactual (i.e., trends in the outcome in the post-intervention period had the jurisdiction not enacted the reform) based on the pre-intervention trends and/or a control group [ 42 , 43 ].

Differences-in-differences (DD) designs, which compare the before vs. after change in an outcome in jurisdictions that experienced an abortion law reform to the corresponding change in the places that did not experience such a change, under the assumption of parallel trends [ 44 , 45 ].

Synthetic controls (SC) approaches, which use a weighted combination of control units that did not experience the intervention, selected to match the treated unit in its pre-intervention outcome trend, to proxy the counterfactual scenario [ 46 , 47 ].

Regression discontinuity (RD) designs, which in the case of eligibility for abortion services being determined by the value of a continuous random variable, such as age or income, would compare the distributions of post-intervention outcomes for those just above and below the threshold [ 48 ].

There is heterogeneity in the terminology and definitions used to describe quasi-experimental designs, but we will do our best to categorize studies into the above groups based on their designs, identification strategies, and assumptions.

Our focus is on quasi-experimental research because we are interested in studies evaluating the effect of population-level interventions (i.e., abortion law reform) with a design that permits inference regarding the causal effect of abortion legislation, which is not possible from other types of observational designs such as cross-sectional studies, cohort studies or case-control studies that lack an identification strategy for addressing sources of unmeasured confounding (e.g., secular trends in outcomes). We are not excluding randomized studies such as randomized controlled trials, cluster randomized trials, or stepped-wedge cluster-randomized trials; however, we do not expect to identify any relevant randomized studies given that abortion policy is unlikely to be randomly assigned. Since our objective is to provide a summary of empirical studies reporting primary research, reviews/meta-analyses, qualitative studies, editorials, letters, book reviews, correspondence, and case reports/studies will also be excluded.

Our population of interest includes women of reproductive age (15–49 years) residing in LMICs, as the policy exposure of interest applies primarily to women who have a demand for sexual and reproductive health services including abortion.

Intervention

The intervention in this study refers to a change in abortion law or policy, either from a restrictive policy to a non-restrictive or less restrictive one, or vice versa. This can, for example, include a change from abortion prohibition in all circumstances to abortion permissible in other circumstances, such as to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, or on request with no requirement for justification. It can also include the abolition of existing abortion policies or the introduction of new policies including those occurring outside the penal code, which also have legal standing, such as:

National constitutions;

Supreme court decisions, as well as higher court decisions;

Customary or religious law, such as interpretations of Muslim law;

Medical ethical codes; and

Regulatory standards and guidelines governing the provision of abortion.

We will also consider national and sub-national reforms, although we anticipate that most reforms will operate at the national level.

The comparison group represents the counterfactual scenario, specifically the level and/or trend of a particular post-intervention outcome in the treated jurisdiction that experienced an abortion law reform had it, counter to the fact, not experienced this specific intervention. Comparison groups will vary depending on the type of quasi-experimental design. These may include outcome trends after abortion reform in the same country, as in the case of an interrupted time series design without a control group, or corresponding trends in countries that did not experience a change in abortion law, as in the case of the difference-in-differences design.

Outcome measures

Primary outcomes.

Access to abortion services: There is no consensus on how to measure access but we will use the following indicators, based on the relevant literature [ 49 ]: [ 1 ] the availability of trained staff to provide care, [ 2 ] facilities are geographically accessible such as distance to providers, [ 3 ] essential equipment, supplies and medications, [ 4 ] services provided regardless of woman’s ability to pay, [ 5 ] all aspects of abortion care are explained to women, [ 6 ] whether staff offer respectful care, [ 7 ] if staff work to ensure privacy, [ 8 ] if high-quality, supportive counseling is provided, [ 9 ] if services are offered in a timely manner, and [ 10 ] if women have the opportunity to express concerns, ask questions, and receive answers.

Use of abortion services refers to induced pregnancy termination, including medication abortion and number of women treated for abortion-related complications.

Secondary outcomes

Current use of any method of contraception refers to women of reproductive age currently using any method contraceptive method.

Future use of contraception refers to women of reproductive age who are not currently using contraception but intend to do so in the future.

Demand for family planning refers to women of reproductive age who are currently using, or whose sexual partner is currently using, at least one contraceptive method.

Unmet need for family planning refers to women of reproductive age who want to stop or delay childbearing but are not using any method of contraception.

Fertility rate refers to the average number of children born to women of childbearing age.

Neonatal morbidity and mortality refer to disability or death of newborn babies within the first 28 days of life.

Maternal morbidity and mortality refer to disability or death due to complications from pregnancy or childbirth.

There will be no language, date, or year restrictions on studies included in this systematic review.

Studies have to be conducted in a low- and middle-income country. We will use the country classification specified in the World Bank Data Catalogue to identify LMICs (Additional file 2 ).

Search methods

We will perform searches for eligible peer-reviewed studies in the following electronic databases.

Ovid MEDLINE(R) (from 1946 to present)

Embase Classic+Embase on OvidSP (from 1947 to present)

CINAHL (1973 to present); and

Web of Science (1900 to present)

The reference list of included studies will be hand searched for additional potentially relevant citations. Additionally, a grey literature search for reports or working papers will be done with the help of Google and Social Science Research Network (SSRN).

Search strategy

A search strategy, based on the eligibility criteria and combining subject indexing terms (i.e., MeSH) and free-text search terms in the title and abstract fields, will be developed for each electronic database. The search strategy will combine terms related to the interventions of interest (i.e., abortion law/policy), etiology (i.e., impact/effect), and context (i.e., LMICs) and will be developed with the help of a subject matter librarian. We opted not to specify outcomes in the search strategy in order to maximize the sensitivity of our search. See Additional file 3 for a draft of our search strategy.

Data collection and analysis

Data management.

Search results from all databases will be imported into Endnote reference manager software (Version X9, Clarivate Analytics) where duplicate records will be identified and excluded using a systematic, rigorous, and reproducible method that utilizes a sequential combination of fields including author, year, title, journal, and pages. Rayyan systematic review software will be used to manage records throughout the review [ 50 ].

Selection process

Two review authors will screen titles and abstracts and apply the eligibility criteria to select studies for full-text review. Reference lists of any relevant articles identified will be screened to ensure no primary research studies are missed. Studies in a language different from English will be translated by collaborators who are fluent in the particular language. If no such expertise is identified, we will use Google Translate [ 51 ]. Full text versions of potentially relevant articles will be retrieved and assessed for inclusion based on study eligibility criteria. Discrepancies will be resolved by consensus or will involve a third reviewer as an arbitrator. The selection of studies, as well as reasons for exclusions of potentially eligible studies, will be described using a PRISMA flow chart.

Data extraction

Data extraction will be independently undertaken by two authors. At the conclusion of data extraction, these two authors will meet with the third author to resolve any discrepancies. A piloted standardized extraction form will be used to extract the following information: authors, date of publication, country of study, aim of study, policy reform year, type of policy reform, data source (surveys, medical records), years compared (before and after the reform), comparators (over time or between groups), participant characteristics (age, socioeconomic status), primary and secondary outcomes, evaluation design, methods used for statistical analysis (regression), estimates reported (means, rates, proportion), information to assess risk of bias (sensitivity analyses), sources of funding, and any potential conflicts of interest.

Risk of bias and quality assessment

Two independent reviewers with content and methodological expertise in methods for policy evaluation will assess the methodological quality of included studies using the quasi-experimental study designs series risk of bias checklist [ 52 ]. This checklist provides a list of criteria for grading the quality of quasi-experimental studies that relate directly to the intrinsic strength of the studies in inferring causality. These include [ 1 ] relevant comparison, [ 2 ] number of times outcome assessments were available, [ 3 ] intervention effect estimated by changes over time for the same or different groups, [ 4 ] control of confounding, [ 5 ] how groups of individuals or clusters were formed (time or location differences), and [ 6 ] assessment of outcome variables. Each of the following domains will be assigned a “yes,” “no,” or “possibly” bias classification. Any discrepancies will be resolved by consensus or a third reviewer with expertise in review methodology if required.

Confidence in cumulative evidence

The strength of the body of evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system [ 53 ].

Data synthesis

We anticipate that risk of bias and heterogeneity in the studies included may preclude the use of meta-analyses to describe pooled effects. This may necessitate the presentation of our main findings through a narrative description. We will synthesize the findings from the included articles according to the following key headings:

Information on the differential aspects of the abortion policy reforms.

Information on the types of study design used to assess the impact of policy reforms.

Information on main effects of abortion law reforms on primary and secondary outcomes of interest.

Information on heterogeneity in the results that might be due to differences in study designs, individual-level characteristics, and contextual factors.

Potential meta-analysis

If outcomes are reported consistently across studies, we will construct forest plots and synthesize effect estimates using meta-analysis. Statistical heterogeneity will be assessed using the I 2 test where I 2 values over 50% indicate moderate to high heterogeneity [ 54 ]. If studies are sufficiently homogenous, we will use fixed effects. However, if there is evidence of heterogeneity, a random effects model will be adopted. Summary measures, including risk ratios or differences or prevalence ratios or differences will be calculated, along with 95% confidence intervals (CI).

Analysis of subgroups

If there are sufficient numbers of included studies, we will perform sub-group analyses according to type of policy reform, geographical location and type of participant characteristics such as age groups, socioeconomic status, urban/rural status, education, or marital status to examine the evidence for heterogeneous effects of abortion laws.

Sensitivity analysis

Sensitivity analyses will be conducted if there are major differences in quality of the included articles to explore the influence of risk of bias on effect estimates.

Meta-biases

If available, studies will be compared to protocols and registers to identify potential reporting bias within studies. If appropriate and there are a sufficient number of studies included, funnel plots will be generated to determine potential publication bias.

This systematic review will synthesize current evidence on the impact of abortion law reforms on women’s health. It aims to identify which legislative reforms are effective, for which population sub-groups, and under which conditions.

Potential limitations may include the low quality of included studies as a result of suboptimal study design, invalid assumptions, lack of sensitivity analysis, imprecision of estimates, variability in results, missing data, and poor outcome measurements. Our review may also include a limited number of articles because we opted to focus on evidence from quasi-experimental study design due to the causal nature of the research question under review. Nonetheless, we will synthesize the literature, provide a critical evaluation of the quality of the evidence and discuss the potential effects of any limitations to our overall conclusions. Protocol amendments will be recorded and dated using the registration for this review on PROSPERO. We will also describe any amendments in our final manuscript.

Synthesizing available evidence on the impact of abortion law reforms represents an important step towards building our knowledge base regarding how abortion law reforms affect women’s health services and health outcomes; we will provide evidence on emerging strategies to influence policy reforms, implement abortion services, and scale up accessibility. This review will be of interest to service providers, policy makers and researchers seeking to improve women’s access to safe abortion around the world.

Abbreviations

Cumulative index to nursing and allied health literature

Excerpta medica database

Low- and middle-income countries

Preferred reporting items for systematic review and meta-analysis protocols

International prospective register of systematic reviews

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Acknowledgements

We thank Genevieve Gore, Liaison Librarian at McGill University, for her assistance with refining the research question, keywords, and Mesh terms for the preliminary search strategy.

The authors acknowledge funding from the Fonds de recherche du Quebec – Santé (FRQS) PhD doctoral awards and Canadian Institutes of Health Research (CIHR) Operating Grant, “Examining the impact of social policies on health equity” (ROH-115209).

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FI and AN conceived and designed the protocol. FI drafted the manuscript. FI, UVU, and AN revised the manuscript and approved its final version.

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Supplementary Information

Additional file 1:.

PRISMA-P 2015 Checklist. This checklist has been adapted for use with systematic review protocol submissions to BioMed Central journals from Table 3 in Moher D et al: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews 2015 4:1

Additional File 2:.

LMICs according to World Bank Data Catalogue. Country classification specified in the World Bank Data Catalogue to identify low- and middle-income countries

Additional File 3: Table 1

. Search strategy in Embase. Detailed search terms and filters applied to generate our search in Embase

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Ishola, F., Ukah, U.V. & Nandi, A. Impact of abortion law reforms on women’s health services and outcomes: a systematic review protocol. Syst Rev 10 , 192 (2021). https://doi.org/10.1186/s13643-021-01739-w

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Received : 02 January 2020

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DOI : https://doi.org/10.1186/s13643-021-01739-w

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Abortion law/policies; Impact
Unsafe abortion
Contraception

Systematic Reviews

ISSN: 2046-4053

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Research Article

Improving measures of access to legal abortion: A validation study triangulating multiple data sources to assess a global indicator

Roles Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing

Affiliations Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina, Department of Maternal & Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America

Affiliations Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina, Department of Health Science, Kinesiology, and Rehabilitation, Universidad Nacional de La Matanza, Buenos Aires, Argentina

Affiliation Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina

Roles Conceptualization, Methodology, Writing – review & editing

Affiliation Department of Population, Family, and Reproductive Health, University of Ghana School of Public Health, Accra, Ghana

Roles Formal analysis, Methodology, Project administration, Writing – review & editing

Affiliation Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Greater Accra, Ghana

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing

Roles Data curation, Formal analysis, Investigation, Methodology, Writing – review & editing

Affiliation Population Council, New Delhi, India

Roles Data curation, Formal analysis, Software, Supervision, Writing – review & editing

Affiliation Department of Global Health and Population, Women and Health Initiative, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

Roles Data curation, Formal analysis, Investigation, Writing – review & editing

Roles Funding acquisition, Supervision, Writing – review & editing

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Writing – review & editing

[ ... ],

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

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Caitlin R. Williams,
Paula Vázquez,
Carolina Nigri,
Richard M. Adanu,
Delia A. B. Bandoh,
Mabel Berrueta,
Suchandrima Chakraborty,
Jewel Gausman,
Ernest Kenu,

Published: January 13, 2023
https://doi.org/10.1371/journal.pone.0280411
Peer Review
Reader Comments

Global mechanisms have been established to monitor and facilitate state accountability regarding the legal status of abortion. However, there is little evidence describing whether these mechanisms capture accurate data. Moreover, it is uncertain whether the “legal status of abortion” is a valid proxy measure for access to safe abortion, pursuant to the global goals of reducing preventable maternal mortality and advancing reproductive rights. Therefore, this study sought to assess the accuracy of reported monitoring data, and to determine whether evidence supports the consistent application of domestic law by health care professionals such that legality of abortion functions as a valid indicator of access.

Methods and findings

We conducted a validation study using three countries as illustrative case examples: Argentina, Ghana, and India. We compared data reported by two global monitoring mechanisms (Countdown to 2030 and the Global Abortion Policies Database) against domestic source documents collected through in-depth policy review. We then surveyed health care professionals authorized to perform abortions about their knowledge of abortion law in their countries and their personal attitudes and practices regarding provision of legal abortion. We compared professionals’ responses to the domestic legal frameworks described in the source documents to establish whether professionals consistently applied the law as written.

This analysis revealed weaknesses in the criterion validity and construct validity of the “legal status of abortion” indicator. We detected discrepancies between data reported by the global monitoring and accountability mechanisms and the domestic policy reviews, even though all referenced the same source documents. Further, provider surveys unearthed important context-specific barriers to legal abortion not captured by the indicator, including conscientious objection and imposition of restrictions at the provider’s discretion.

Conclusions

Taken together, these findings denote weaknesses in the indicator “legal status of abortion” as a proxy for access to safe abortion, as well as inaccuracies in data reported to global monitoring mechanisms. This information provides important groundwork for strengthening indicators for monitoring access to abortion and for renewed advocacy to assure abortion rights worldwide.

Citation: Williams CR, Vázquez P, Nigri C, Adanu RM, Bandoh DAB, Berrueta M, et al. (2023) Improving measures of access to legal abortion: A validation study triangulating multiple data sources to assess a global indicator. PLoS ONE 18(1): e0280411. https://doi.org/10.1371/journal.pone.0280411

Editor: Andrea Cioffi, University of Foggia: Universita degli Studi di Foggia, ITALY

Received: September 9, 2022; Accepted: December 22, 2022; Published: January 13, 2023

Copyright: © 2023 Williams et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data have been anonymized to ensure compliance with human subject protections and study protocols. The anonymized data underlying the findings are deposited here: Jolivet, Rima; Gausman, Jewel; Adanu, Richard; Bandoh, Delia; Berrueta, Mabel; Chakraborty, Suchandrima; Kenu, Ernest; Khan, Nizamuddin; Odikro, Magdalene; Pingray, Veronica; Ramesh, Sowmya; Vázquez, Paula; Williams, Caitlin; Langer, Ana, 2022, "Validation data for measuring the "Legal Status of Abortion"", https://doi.org/10.7910/DVN/OCOE3B , Harvard Dataverse, V1, UNF:6:S77IPSgJW3AHbZ/gVeX/UA== [fileUNF].

Funding: This work was supported by the Bill and Melinda Gates Foundation: https://www.gatesfoundation.org/ RRJ and AL received the award for Improving Maternal Health Measurement (IMHM) Capacity and Use through which this work was funded, with grant number OPP1169546. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: Countdown, Countdown to 2030; GAPD, Global Abortion Policies Database; OB/GYNs, obstetrician/gynecologists; SDG, Sustainable Development Goals; UN, United Nations; WHO, World Health Organization

Introduction

Unsafe abortion is a leading preventable cause of pregnancy-related mortality and morbidity [ 1 ]. The World Health Organization (WHO) defines unsafe abortions as those performed by individuals without the necessary skills and/or in environments that do not conform to minimal medical standards [ 2 ]. Most unsafe abortions occur in countries where abortion is legally restricted [ 3 ]. Legalizing, or at least decriminalizing, abortion is proposed as one intervention to reduce unsafe abortions and thus maternal morbidity and mortality [ 4 , 5 ]. However, the current international legal landscape is largely heterogenous, undermining efforts to ensure access to safe abortion [ 6 , 7 ]. Further, domestic legislation regarding abortion is in flux in many settings, with some legal regimes becoming more restrictive even as others become more permissive [ 7 – 12 ]. Several legal grounds for abortion are recognized in international standards: to save a woman’s life; to preserve a woman’s health; in cases of intellectual or cognitive disability of the woman; in cases of rape, gender-based/sexual violence, or incest; in cases of fetal anomaly or impairment; for economic or social reasons; and upon a woman’s request [ 13 , 14 ].

Efforts within the international human rights space propose monitoring the legal status of abortion as one way to promote accountability and make the problem of unsafe abortion visible. Examples include human rights accountability mechanisms such as the Universal Periodic Review—a peer-review mechanism led by the United Nations (UN) Human Rights Council whereby every member state’s human rights record is reviewed and recommendations are issued to strengthen compliance with international human rights standards [ 15 ]—and the Committee on the Elimination of All Forms of Discrimination Against Women’s periodic review—similarly focused on women’s rights. Treaty bodies have successfully leveraged these mechanisms to induce states to take action to assure that domestic abortion legislation complies with international human rights standards [ 16 – 19 ].

With the mainstreaming of human rights across the UN [ 20 ], health-related UN agencies have begun to track the legal status of abortion as a proxy for and upstream determinant of access to safe abortion. In 2017, WHO and the UN Department of Economic and Social Affairs launched the Global Abortion Policies Database (GAPD), which compiles data on the legal status of abortion as reported by each country’s Ministry of Health or relevant national agencies/institutions [ 21 , 22 ]. Similarly, Countdown to 2030 (hereafter, Countdown) arises from a collaboration of academics, UN agencies, the World Bank, and civil society to track progress toward the health-related Sustainable Development Goals [ 23 ] and includes “legal status of abortion” as reported by the UN Population Division in its policy indicators [ 24 ]. Such groundbreaking efforts firmly establish legal abortion within a rights framework and provide an accountability mechanism for monitoring.

Despite these important advances, it remains unclear whether these monitoring efforts reflect the reality of access to abortions accurately and comprehensively such that the legal status of abortion can be used with confidence as a proxy measure for access to safe, legal abortion. A 2019 landscape analysis commissioned by the WHO “Mother and Newborn Information for Tracking Outcomes and Results” (MoNITOR) expert working group specifically flagged the lack of research evidence assessing the validity of indicators to monitor abortion care. The authors found that, in general, system- and policy-level maternal and newborn health indicators are seldom research-validated. Further, data on indicator validity was found to be poorly communicated in low- and middle-income countries, raising concerns about indicator selection in these settings [ 25 ].

Moreover, it is unclear whether monitoring data reported by countries are accurate. Indeed, an initial WHO review of GAPD data suggests there may be numerous inaccuracies [ 22 ]. In addition, both GAPD and Countdown consider only national legislation, which may not fully capture domestic policy landscapes—sub-national regulations, clinical guidelines, and other policy documents may also structure domestic legal frameworks [ 26 , 27 ]. These limitations challenge the criterion validity of the policy indicator, i.e., how well the indicator reflects actual policy.

Conceptually, the legal status of abortion may be a poor proxy for the accessibility of legal or safe abortion [ 28 ]—compliance with existing laws may be inconsistent [ 26 , 29 , 30 ], health facilities and healthcare providers may have differing interpretations of legal constructs [ 30 , 31 ], and some legal constructs may be more subject to variance in interpretation and implementation than others [ 32 , 33 ]. Facilities and providers may also discriminate in providing access to abortion, regardless of legality [ 34 , 35 ]. Thus, rights as guaranteed on paper may differ from rights enjoyed in practice. These limitations threaten the construct validity of the policy indicator, i.e., how well it captures the concept of accessibility of legal abortion. Determining the criterion and construct validity of this indicator is important to develop a more valid approach to assessing women’s access to abortion, which itself will bolster efforts to hold duty-bearers accountable to this health-related right.

Ensuring monitoring data are accurate and reflect implementation of the law (not just its existence) is essential for promoting reproductive health and rights [ 26 ]. Thus, this study aims to assess the validity of a critical policy indicator for ending preventable maternal deaths by: verifying that the legal status of abortion was accurately reported to GAPD and Countdown via in-depth policy analysis (criterion validity), and exploring whether there is provider-level variation in the implementation of domestic abortion law (construct validity) in three diverse countries (Argentina, Ghana, and India). This indicator validation study is part of a larger effort to validate ten policy indicators drawn from the monitoring framework for the “Strategies toward Ending Preventable Maternal Mortality (EPMM)” [ 36 ].

Study design

This is a cross-sectional, observational study design using multiple sources of data. We collected secondary data through policy review and primary data through cross-sectional survey of healthcare providers to address two validation questions, respectively:

How does the law—as expressed in national (and where relevant, subnational) legislative, regulatory, and policy documents—compare to the Countdown indicator metadata and information available in GAPD?
Is there evidence that providers are consistently applying the law for each of the grounds on which abortion is legal?

Participants and sampling

Three LMIC research settings (Argentina, Ghana, and India) were purposively selected for the larger research project of which this study is part, based on geographic diversity across those world regions reflecting the highest burden of maternal mortality and demonstrated local research capacity. Primary data were collected in four districts/provinces of each country that were selected systematically using a multi-stage standardized sampling plan that took into consideration variations in health system performance, geographic location, population served, and other forms of diversity. This selection process is detailed elsewhere [ 36 ]. Within each district/province, we replicated the Demographic and Health Survey methodology [ 37 ] to define primary sampling units within each jurisdiction and randomly selected 20 units. All facilities offering abortion services within each primary sampling unit were included.

Study participants were drawn from healthcare providers on the payroll in participating health facilities who belonged to professional cadres legally authorized to provide abortion. The managers of participating facilities provided lists of eligible providers in that facility. In Argentina, this included obstetricians/gynecologists (OB/GYNs) and general practice physicians employed as sexual and reproductive health providers. In Ghana, all OB/GYNs, general practice physicians, and midwives were eligible to participate. In India, OB/GYNs and general practice physicians with abortion certification were eligible. Participants were considered eligible if they were authorized to provide abortion care, were currently working in a participating center, and provided consent to participate. Exclusion criteria included providers on extended sick leave or those unable or unwilling to provide consent.

Data collection and management

To address the first validation question, we extracted data from the most recent country profiles in Countdown (8 August 2020) and GAPD (last updated 15 June 2021 for Argentina; 7 May 2017 for Ghana; and 15 June 2021 for India). Countdown metadata only included data on legal grounds for abortion, while GAPD included data on legal grounds for abortion and details on additional requirements to access abortion. We then conducted a comprehensive desk review of national (and, as relevant, subnational) policy through October 2021 in Argentina, July 2021 in Ghana, and July 2021 in India.

In Argentina, we systematically searched two electronic legal databases [InfoLEG ( http://www.infoleg.gob.ar ) and Sistema Argentino de Información Jurídica ( http://www.saij.gob.ar )] using keywords related to abortion and reviewed the reference lists of peer-reviewed publications on Argentina’s legal landscape regarding abortion. We also manually searched relevant ministerial documents and consulted with subject matter experts to request additional resources and ensure no documents were omitted. The documents reviewed were the National Penal Code (Arts. 85–88); National Civil and Commercial Code (Arts. 22–24, 26); Convention on the Rights of Persons with Disabilities; Law 25,673; Law 26,529; Law 26,485; Law 26,657; Law 23,179; Law 23,313; Law 24,632; Fallo F.A.L. decision; 2019 National Protocol on Care for Persons with the Right to a Legal Abortion; National Essential Medicines List; and relevant Ministerial declarations regarding the use of misoprostol (“ANMAT aclara acerca de producto con misoprostol” [ANMAT clarification regarding products with misoprostol] and “Sobre la autorización de los productos con ingrediente farmacéutico activo Misoprostol” [Regarding the authorization of products with the active pharmaceutical ingredient misoprostol]).

In Ghana, we searched the websites of the Ghana Health Service, Nurses and Midwifery Council, and the Ministry of Health using keywords related to abortion for documents on the legal status of abortion. We also consulted with subject matter experts from the Family Health Division of the Ghana Health Service and the Ministry of Health to ensure all related documents were compiled. The documents ultimately included were Ghana’s 1992 Constitution Act 29, Comprehensive Abortion Care Protocols, and National Reproductive Health standards.

In India, we searched all government and allied portals for legal documents and guidelines using keywords related to abortion. The included reference sources were: Medical Termination of Pregnancy Act of 1971, along with its several amendments (2002, 2003, 2020, 2021); Article 24 of the Constitution; Act Number 45 of the Indian Penal Code of 1860; Pre-Conception and Pre-Natal Diagnostic Techniques Act of 1994; Protection of Children from Sexual Offences Act of 2012; National List of Essential Medicines of India; 1945 Drugs and Cosmetics Rule (amended in 2013); FOGSI & ICOG Good Clinical Practice Recommendation of Medical Termination of Pregnancy; and Government of India’s Comprehensive Abortion Care-Training and Service Delivery Guidelines 2018. We also consulted subject matter experts to request any additional resources and materials to ensure comprehensive review.

To facilitate consistent data collection across countries, we developed a standardized data extraction form with fields for each GAPD-reported criterion: legal grounds for abortion, additional requirements needed to obtain an abortion, and aspects of clinical care. Definitions for each term were based on WHO policy guidance [ 2 ]. Each legal ground was coded as either explicitly permitted, prohibited, or not specified in the reviewed documents. Each additional requirement was coded as either explicitly required, explicitly not required, or not specified in the reviewed documents. All relevant legal documents identified were reviewed and coded independently by two study team members, who resolved discrepancies by consensus. A third team member helped resolve disagreements as needed. Local experts in abortion policy were consulted to verify the local interpretation and identify relevant additional documents, including jurisprudence.

To address the second validation question, we surveyed healthcare providers legally authorized to provide abortions. The surveys sought to: 1) capture respondents’ knowledge of the legal grounds for abortion and any restrictions on abortion in their jurisdictions; and 2) explore providers’ practice patterns to identify possible provider-level variations in the provision of legal abortion. Surveys were conducted July–October 2021 in Argentina, April 2021 in Ghana, and September–December 2020 in India.

Recruitment and data collection procedures varied by country. In Argentina, meetings were held in each participating health facility to explain the project to eligible health providers. The facility data collector than collected email addresses of eligible providers to contact regarding participation. Eligible providers were emailed a link to a secure portal with detailed descriptions of the survey purpose and procedures. Providers who responded to the consent electronically were emailed a secure electronic link to access the survey. Those who elected to respond via a paper-based survey were provided a paper form and asked to complete it in a private room within the facility where they practice. Completed paper-based surveys were sealed in envelopes and transferred to the data center. In Ghana, data were collected via in-person interviews. Due to the sensitivity of abortion data, entries were made directly into the secure online platform by field researchers. Personal identifiers were kept separately in hard copies that were securely stored in a locker dedicated to the study with access restricted to only core study team members. Personal identifiers were not linked to electronic information collected. In India, contact numbers of abortion service providers were obtained from the district health department. Providers were contacted by the field team to obtain consent and schedule a telephone interview. Interviews were conducted in a local language or in English as per healthcare workers’ preference, with most conducted in English. Hard copies of the forms filled by interviewers during the telephone interviews were stored in a secured locker with access restricted to project personnel. Survey responses were de-identified, entered, and stored in a dedicated, secure web-based study platform with validation checks. All countries used the same password-protected secure web-based study platform (REDCap version 11.2.2).

For the first validation question, we conducted comparative analysis of domestic legal frameworks (hereafter, “validation data”; considered the gold standard) and information reported in the global monitoring mechanisms (Countdown and GAPD country profiles) regarding legal grounds, requirements, and restrictions for each country. We drew from legal mapping and policy surveillance methodologies successfully used to identify variation in sources and abortion regulatory requirements [ 32 , 38 – 42 ]. Rather than using distinct political entities (e.g., states or subnational units) as the unit of analysis, we compared differences across three data sources for the same political/governance unit.

To address the second validation question, we conducted descriptive analyses of the survey data, stratified by country. First, we calculated descriptive statistics for respondents in each country. Next, we tabulated the proportion of providers who: a) correctly identified whether a given ground for abortion was legal in their country; b) incorrectly believed that the provision of abortion on each ground was conditioned upon specific restrictions/additional requirements that were not stipulated by law; c) indicated they would personally perform an abortion on each of the grounds they indicated are legal; and d) reported having personal practices that imposed other barriers to abortion beyond those required by law. Finally, we compiled the responses for reasons for not performing an abortion for each legal ground. Surveys with missing data for some fields were included in the analysis; those returned blank were excluded. Data from the desk review of policy documents (national and, where relevant, subnational legal frameworks) served as the gold standard for comparison. Analysis was conducted using Stata version 15.1 (StataCorp, College Station, TX, USA).

Ethical considerations

The study and informed consent process and forms were approved by the Office of Human Research Administration at Harvard University (IRB19-1086) and local institutional review boards [ Argentina : Comité de Ética de la Investigación de la Provincia de Jujuy (approval ID not applicable), Comisión Provincial de Investigaciones Biomédicas de la Provincia de Salta (approval ID 321-284616/2019), Consejo Provincial de Bioética de la Provincia de La Pampa (approval ID not applicable), Comité de Ética Central de la Provincia de Buenos Aires (approval ID 2919-2056-2019); India : Sigma-IRB (IRB number: 10052/IRB/19-20); Ghana : Ghana Health Service Ethical Review Committee (approval number GHS-ERC022/08/19)].

All participants provided written informed consent. During the recruitment and informed consent processes, particular emphasis was put on the voluntary nature of participation, precautions taken to secure and de-identify data, the respondent’s ability to withdraw at any time, and the data protection procedures. Potential participants were encouraged to ask questions regarding the survey and given opportunities to discuss any concerns with local study coordinators.

We carefully protected anonymity and confidentiality of the data throughout the entire data cycle (collection, entry, analysis). The recruitment process minimized the possibility that colleagues and supervisors would know whether participants were in the study. None of the study team members involved in recruitment or data analysis could see which providers decided to participate in the study or could access identifiable data. The data manager overseeing survey administration did not have access to the list of provider names or the content of respondent surveys. Data entry personnel did not have access to the list of provider names or any identifying information. To reduce the risk of deductive disclosure, data were aggregated such that the individual province/district, facility, or provider could not be identified. We blinded provinces/districts and reported them by assigning random numbers (1–4).

Legal framework for abortion, as reported in global monitoring frameworks

For each ground for abortion, we specified whether it was legal, not legal, not specified, or not reported by each source ( Table 1 ). For Argentina, Countdown and GAPD reported that economic or social reasons did not constitute legal grounds, although the current domestic legal framework leaves this unspecified. For Ghana, GAPD reported that saving a woman’s health, intellectual or cognitive disability of the woman, and economic or social reasons did not constitute legal grounds; however, the domestic legal framework considered them to be legal grounds. In addition, Countdown reported that abortion was legal at a woman’s request, while domestic law in Ghana documented it was not. For India, GAPD reported that preserving a woman’s health, intellectual or cognitive disability of the woman, incest, rape, and economic and social reasons were not legal grounds; in contrast, the Indian domestic framework indicated all were legal grounds. In addition, Countdown reported that incest was not a legal ground and did not specify whether rape constituted a legal ground in India, although both were legal grounds per domestic sources. The documents cited by GAPD for all three countries were the same as those reviewed by our team.

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https://doi.org/10.1371/journal.pone.0280411.t001

Health care providers’ knowledge and application of the law

In Argentina, 89 of 112 eligible providers consented to participate (79.5% consent rate); 87 of those who consented completed the survey (97.8% response rate). The sample was unevenly split across the four participating provinces, with Province 2 contributing 41.4% of the sample and Province 3 contributing 10.3%. All participants worked in public facilities, and the majority worked in tertiary-level facilities (66.7%), were female (65.5%), and were experienced (median years of practice: 12.0) ( Table 2 ).

https://doi.org/10.1371/journal.pone.0280411.t002

Most respondents knew that abortion was legal to save a woman’s life, to preserve a woman’s health (overall, physical, mental), in cases of rape, and on request (proportions ranged 81.6%–96.5% across the six legal grounds). Only 5.7% indicated that cases of intellectual or cognitive disability of the woman and 13.8% that cases of incest were not explicit legal grounds for abortion. Only 10.3% and 17.2% of respondents knew that cases of fetal impairment and economic or social reasons, respectively, did not constitute explicit legal grounds for abortion ( Table 3 ).

https://doi.org/10.1371/journal.pone.0280411.t003

While most respondents (>90%) knew that abortion was legal to save a woman’s life and when the pregnancy was the result of rape, half of respondents were not personally willing to perform an abortion on these two grounds (52.4% and 47.4%, respectively). Less than half were willing to perform an abortion to preserve a woman’s health (47.1% for physical health, 42.9% for mental health, and 42.6% for health overall). Further, 42.3% said they would perform an abortion on a woman’s request. The main reason for refusing to provide an abortion, irrespective of grounds, was personal religious or moral beliefs (i.e., self-identified as a conscientious objector) ( Table 3 ).

Some respondents believed that additional restrictions to abortion access were required, though these were not legally specified. Varying by grounds, respondents thought there were gestational age limits (range: 25.0%–50.0%), that abortion was only authorized in specially licensed facilities (40.5%–64.7%), that authorization of one or more other professionals was required to perform an abortion (23.5%–50.0%), that parental consent was required for at least some minors (40.8%–55.7%), and that it was necessary to seek judicial authorization to perform an abortion on someone younger than 18 (16.4%–35.3%). For all six legal grounds, some respondents said they would require a woman to undergo compulsory counseling (22.4%–41.2%), insist on a compulsory waiting period (9.5%–19.7%), and prohibit the detection of fetal sex before performing the abortion (14.3%–35.7%) ( Table 4 ).

https://doi.org/10.1371/journal.pone.0280411.t004

In Ghana, 513 of 524 eligible providers consented to participate (97.9% consent rate). A total of 513 providers completed the survey (97.9% response rate), with 79.1% from a single district (District 2). The majority of respondents were from primary level facilities (58.7%). Most respondents worked in the public sector (87.3%) and were female (87.1%). Respondents had a range of 0–40 years in practice (median: 2.0) ( Table 2 ).

Respondents had generally high knowledge of the grounds under which abortion was legal in Ghana. Nearly all (99.2%) knew that abortion was legal to save a woman’s life. Most knew that abortion was legal to preserve a woman’s health (80.5% for physical health, 77.6% for mental health, and 88.3% for overall health). Fewer respondents (61.6%) knew that abortion was legal in cases of intellectual or cognitive disability of the woman. The majority of respondents identified incest, rape, and fetal impairment as legal grounds for abortion (72.9%, 82.8%, and 86.9%, respectively). Yet only 33.3% knew that abortion was legal for economic or social reasons, and only 50.3% realized that abortion on request was explicitly not legal.

For each of the grounds upon which abortion is legal in Ghana, most respondents indicated willingness to perform the procedure, ranging from 75.4% for economic or social reasons to 86.2% to preserve a woman’s health. Among those who indicated that they would not be willing to perform an abortion, personal religious or moral reasons were most frequently cited ( Table 3 ).

Some respondents thought there existed restrictions and requirements not specified in the law. Most respondents believed that abortion was only authorized in specially licensed facilities (range: 86.4%–94.7%, depending on the legal ground). Many stated that to perform an abortion they would require the authorization of one or more healthcare professionals (63.7%–82.9%), parental consent for adolescents and girls under 18 (81.7%–93.5%), spousal consent for married women (62.0%–82.3%), compulsory counseling (78.4%–93.6%), and compulsory ultrasound or Doppler to listen to the fetal heartbeat (65.2%–77.6%). Fewer respondents stated that they would require a compulsory waiting period (15.3%–34.5%) or prohibit detection of fetal sex (20.7%–31.3%) before performing the abortion ( Table 5 ).

https://doi.org/10.1371/journal.pone.0280411.t005

In India, 95 of 106 eligible providers consented to participate (89.6% consent rate). All 95 providers who consented to participate completed the survey (100.0% response rate). The population was distributed across the four participating districts, with one district contributing 36.8% of the sample. All providers worked in the public sector. A majority of participants worked in secondary- and tertiary-level facilities in the study districts (47.4% and 40.0%, respectively) and most were female (95.8%). Respondents reported a range of 1–36 years of practice experience (median: 7.0) ( Table 2 ).

Respondents’ knowledge of the legal grounds for abortion was generally high, with >90% correctly indicating all legal grounds for performing an abortion (range: 81.0%–100%, varying by ground). Comparatively, fewer knew abortion was not explicitly legal on request (39.0%). Respondents’ willingness to perform an abortion varied notably based on the grounds, with far more respondents reportedly willing to perform an abortion to save a woman’s life (81.1%) than for economic or social reasons (55.3%) or to preserve a woman’s physical or mental health (47.9% and 51.1%, respectively). The reason most frequently given for not performing an abortion across all grounds was lack of clinical capacity (25.0%–60.6%) ( Table 3 ).

Some respondents believed that additional restrictions to abortion access were required, although they were not legally specified. Many believed providers could legally "opt-out" of providing an abortion (range: 44.2%–85.9%, depending on ground). A proportion believed that providers who “opted out” of performing an abortion had no obligation to refer the woman to another provider (7.7%–43.8%). By law in India, 1–2 physicians must authorize an abortion, but there was confusion about which physicians could provide such authorization. For example, respondents believed that generalist physicians (72.1%–85.1%) and specialist physicians including OB/GYNs (6.6%–15.3%) were not permitted to provide authorization (data not shown). In addition, some respondents erroneously stated that adolescents and girls under the age of 18 required judicial authorization to access legal abortion (25.6%–72.7%). Further, 25.3% said they would require spousal consent before performing an abortion to save a woman’s life, while 85.9% would require spousal consent for economic or social reasons. Responses were similarly heterogeneous for other types of requirements among the legal grounds, such as requiring a woman to view ultrasound images or listen to the fetal heartbeat, endure a compulsory waiting period, or undergo HIV or other STI tests ( Table 6 ).

https://doi.org/10.1371/journal.pone.0280411.t006

This study sought to validate the accuracy of data reported by global monitoring mechanisms and determine whether domestic laws are being implemented as written, to assess use of the “legal status of abortion” as a proxy for actual access to legal abortion. We identified discrepancies between the global monitoring mechanisms and domestic policy review, although all referenced the same source documents. Specifically, we found variation between the data reported by Countdown and GAPD and the validation data in Ghana and India, while data reported for Argentina were accurate according to our findings. The provider surveys offered substantial evidence that domestic laws were not reliably being implemented as written, including due to conscientious objection and imposition of restrictions at the provider’s discretion (e.g., soliciting parental or spousal consent when not required by law) in the three countries. Our results raise important questions regarding the validity of the indicator as a measure of access to legal abortion and also the accuracy of global data collection on laws governing abortion and policy implementation.

Given that the documents cited by GAPD for the three countries are the same as those selected through the desk review, the discrepancies observed are probably not due to omission of key documents but to varied interpretation. It is possible that the legal interpretation in force has evolved since the data reported in Countdown and GAPD were compiled, leading to the identified discrepancies. Researchers, advocates, and decision-makers working on abortion policy may elect to review local documentation and consult local subject matter experts to complement data reported in Countdown and GAPD to ensure a complete legal picture. Our findings are consistent with the results of WHO’s own internal validation of the data reported in GAPD, which found extensive mismatch between reported data and uploaded source documents, and many entries that could not be validated based on provided source documents [ 22 ]. These findings raise questions about accuracy of the data reported in global monitoring frameworks.

While global monitoring frameworks focus on the overall legal status of abortion, the existence of progressive abortion legislation does not guarantee implementation. Gaps in provider knowledge about the legality of abortion can hinder implementation, as can provider-imposed barriers that go above and beyond the law [ 43 ]. The provider surveys in our study surfaced evidence of provider-level barriers to accessing legal abortion in all three countries.

In Argentina, the landmark December 2020 legislation legalizing abortion on request up through 14 weeks and 6 days of gestation dramatically expanded access to legal abortion, including by harmonizing the domestic legal framework through the passage of a single nationally applicable law. However, widespread conscientious objection may curtail access despite the favorable legal context. Previous research in Argentina suggests conscientious objection may be multi-faceted, reflecting stigma, positions of hospital leadership, and workload as much as personal religious and moral beliefs [ 35 ]. High rates of conscientious objection may leave facilities with few providers willing to perform abortions [ 44 – 47 ]. Despite the legal obligation to refer to a non-objecting provider, pervasive refusals may force women to travel further, incur additional costs, and face delays [ 47 , 48 ]. The Argentine Ministry of Health states that conscientious objection must not hinder abortion access and that conscientious objector status may be overruled in emergencies or when no other professional is available [ 49 ], thus aligning Argentine policy with global guidance regarding conscientious objection [ 50 ]. Still, further research is needed to understand if such common conscientious objection in practice translates to reduced access. In the meantime, provider training to increase knowledge not only of the laws surrounding abortion but the ethics of conscientious objection may be merited, in light of the potential impact on the right to health [ 51 ].

In Ghana, despite a generally high level of knowledge about the grounds on which abortion is legal, respondents held many erroneous beliefs about the existence of additional restrictions or requirements for providing abortion on those grounds. Although providers did not often cite being conscientious objectors, it is possible that providers’ responses regarding imposing additional discretional barriers to access may reflect providers’ religious and personal ideologies relating to abortion (particularly given the largely Christian religious base of the country). Other research suggests that ambiguity in abortion law combined with low provider knowledge may fuel misinterpretations and provider-level barriers [ 52 ]. Further, censure from colleagues may cause providers to artificially constrain access to avoid performing abortions and become stigmatized by association [ 34 ]. Clarifying policy guidance combined with provider education may help ensure provider-level barriers do not impede access and violate rights.

In India, our findings were mixed. We found a high degree of knowledge of the legal grounds for abortion and of restrictions for which the law is clear. However, many restrictions are not expressly permitted or prohibited, and thus providers’ reported knowledge and practices showed substantial variation. It can be challenging for busy medical practitioners to stay abreast of guideline changes, which may result in women having different experiences when attempting to access care. Policies that clearly specify the legal requirements to access abortion and explicitly limit the authority to impose additional barriers could help ensure access to the full set of legally guaranteed rights.

Despite differing precedents and legal frameworks, we found commonalities across countries. Certain constructs consistently proved confusing for respondents, namely “compulsory counseling” and “compulsory waiting period.” WHO recommends that all women seeking abortions be offered voluntary, confidential, non-directive options counseling and information regarding abortion methods as a component of quality care, even as it discourages mandatory or directive counseling aimed at dissuading or denying women access to abortion [ 2 ]. Respondents seemed unclear on this distinction, and many expressed confusion regarding this question in the survey. Similarly, some respondents interpreted “compulsory waiting period” as indicating the maximum amount of time that could legally lapse between a woman’s request for an abortion and the health system’s provision of care (e.g., Argentinian national policy explicitly states that the health system must complete the procedure within ten days of the request). These divergent respondent interpretations raise questions about the construct validity of these items in our survey and other policy surveys.

Methodologically, our study has several key strengths. We developed a rigorous, systematic approach to identify all relevant documents and extract data for the secondary review. We also used source documents as the unit of analysis rather than geographic/political units so that policy surveillance methods could be deployed in a validation study. This innovation responds to an identified need to better validate policy indicators [ 36 ]. We also included all providers legally authorized to perform abortions in the survey, not only those who indicated they actively performed abortions. We did this to avoid selection bias and explore the knowledge and provider beliefs that women could encounter when seeking an abortion, allowing us to identify and characterize provider-level barriers. Our systematic approach to document provider knowledge and practice across all legal grounds afforded us a high level of granularity compared to other studies [ 53 ].

Our study also has several limitations. As our policy analysis was descriptive, we cannot identify the causes or contributing factors that led to the discrepancies in different sources, and we cannot comment on the extent to which they affect countries not included in our review. The structured surveys did not probe more deeply into why providers would impose restrictions. For example, facility-level policy may drive these practices, or providers may exert discretional authority to impose additional barriers to sexual and reproductive health care [ 34 , 54 – 56 ]. More research is needed to understand what is driving these reported attitudes and behaviors. Additionally, our study relied on provider self-reports, which may not accurately reflect true practices. Direct observation of the client–provider interaction or use of mystery/simulated clients (actors who present as real abortion clients to assess the quality of care) might produce more accurate representations of actual practice, as done to assess quality of care in family planning [ 57 , 58 ]. Finally, our study only sought to capture providers’ perspectives, not the experiences of women seeking abortion care.

In addition to these general limitations, we encountered some COVID-19-specific limitations. The pandemic delayed launch of the provider surveys in all three countries. This altered the sample in all sites, as some providers declined to participate due to being on medical leave after testing positive for COVID-19 or being redeployed for COVID-19 response. In India, the pandemic complicated completion of interviews and changed the modality of the survey from face-to-face to telephone. In addition, providers who did not consent to participate cited responding to COVID-19 as the rationale for non-participation. In Ghana, individuals who did not consent to the in-person interviews cited being away from work either recovering from COVID-19 infection or supporting family infected by the virus. While the pandemic may have reduced the sample of participants in these settings, there is no reason to believe that the attrition would have been differential or that it would have introduced systematic bias. In Argentina, COVID-19-related delays may have significantly impacted the outcomes of interest, as by chance the domestic legal framework radically changed just before the survey launched. Significant social movements both for and against legalization of abortion on request preceded the historic legislation change, which may have influenced providers’ willingness to participate. This could explain the lower consent rate in Argentina compared to Ghana and India. These limitations mean that our findings should be taken as a detailed snapshot of the moments at which the study was conducted in each country, which can provide insight into the validity and challenges of global monitoring indicators rather than as generalizable findings that can be applied broadly to other contexts and historical moments.

Several global monitoring frameworks track the legal status of abortion, yet there are lingering questions about measurement validity of current indicators. Our findings suggest there may be substantial problems with criterion validity of the “legal status of abortion” indicator for at least some countries. As policymakers, researchers, and advocates routinely use the Countdown and GAPD databases, inaccurate or incomplete information may jeopardize efforts to advance reproductive health and rights. The rapid changes in abortion-related laws around the world also complicate efforts to maintain accurate, complete, and updated records [ 8 , 9 ]. Our findings also suggest construct validity problems both with discrete sub-constructs (e.g., “compulsory counseling” and “compulsory waiting period”) and with the broader construct of “legal status of abortion” as a proxy for access. Indeed, our results suggest that even comparatively liberal legal frameworks can leave open considerable room for differences in provider-level interpretations or implementation of the law, which may obstruct abortion access. Relying solely on the legal status of abortion may lead the sexual and reproductive health and rights community to overstate abortion access and thus neglect efforts to ensure rights. These findings serve as a foundation to develop future studies and as impetus for renewed legal advocacy to assure abortion rights around the globe.

Acknowledgments

The authors would like to thank the following people, without whose efforts the publication of this manuscript would not have been possible:

In Argentina, we gratefully acknowledge the support of the National Directorate of Maternal, Child and Adolescent Health and the Directorate of Sexual and Reproductive Health of the Ministry of Health of the Nation. We commend the commitment and dedication of the provincial teams, and the following members of the Maternal and Child Health Programs of the Provincial Ministries of Health: Dr. Adriana Martirena, Dr. Daniel Nowacky, Dr. Adriana Allones, Marta Ferrary, Dr. Claudia Castro, Ana Seimande, Antonio Tabarcachi, Noelia Coria, Cintia Jacobi, Laura Soto, Dr. Mara Bazán, Dr. Susana Velazco, Dr. Patricia Leal, and Marcela Tapia. Finally, we would like to express our deepest gratitude to all of the health workers who participated in the study as data collectors, working through the height of the COVID-19 pandemic in Argentina.

In Ghana, we gratefully acknowledge the support of the Ghana Health Service Family Health Division, The Director General–Ghana Health Service–Dr. Patrick Kuma-Aboagye; Dr. Ernest Konadu Asiedu, Ms. Roberta Asiedu, Dr. Margretta Chandi and Ms. Catherine Adu Asare; Dr. Benedicta Mensah, Ms. Keziah Dampare, and all regional and district health workers and field teams for their persistence in data collection despite the challenges.

In India, we gratefully acknowledge the support of Dr. Dinesh Baswal, Ex Deputy Commissioner at Maternal Health Division, Ministry of Health & Family Welfare, India; the Mission Directors, State Health Departments of Tamil Nadu and Uttar Pradesh, and the District health Officials of study districts. We also acknowledge the support of Dr. Manju Chhugani and Dr. Renu Kharb for their guidance in review of the secondary data on many indicators. Finally, we sincerely thank the district field teams for their untiring efforts and adaptation to new methodologies to collect good quality data, in the midst of COVID in India. We also thank all the health workers and facility staff who participated in the study despite their busy schedules due to COVID situation.

In addition, we are grateful for the support of Ronnie Johnson and Tiziana Leone whose inputs in the formative stages of this research guided our thinking.

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Open access
Published: 21 November 2018

Knowledge and attitude of women towards the legalization of abortion in the selected town of Ethiopia: a cross sectional study

Tilahun Fufa Debela 1 &
Misgun Shewangizaw Mekuria 2

Reproductive Health volume 15 , Article number: 190 ( 2018 ) Cite this article

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Unsafe abortion contributes to maternal deaths 13% globally and 25–35% of Ethiopia. By considering the problem of unsafe abortion, Ethiopia amended a law that permits abortion under certain circumstances. However, the country liberalized the service, women are still not using it. Therefore, the possible reason might be a lack of knowledge and attitude is a barrier that hinders women to use safe abortion.

A community-based cross-sectional study was conducted in Arba Minch town from January 02 to 17, 2017. Women in the reproductive age groups (15–49) who reside in the town for more than six months were included in the study. The sample size was determined using a single population proportion formula. Five kebeles were selected using the lottery method from 11 kebeles. The proportional allocation of the sample was done for each kebeles. Data were collected using a structured questionnaire. Binary and multiple logistic analyses were carried out to identify factors associated with knowledge & attitude toward legalization of abortion.

A total of 576 women were responded to the question. The finding of our study showed that only 23.4% of women have knowledge about the legalization of abortion. Of all the respondents 323(56%) prefer abortion on demand to be legalized while about 241 (41.9%) do not prefer to be legalized. Again about 57% of women believe that women can use it but the rest 43% believe even if allowed women do not use it. From all participants, 59% don’t want to use by themselves and also, 53.3% don’t think that women would have the right to use the service or terminate their pregnancy even if the pregnancy fulfill the criteria. Ethnicity, marital status, and family size were the factors significantly associated with knowledge. Again, educational status, marital status and having knowledge about the legalization of abortion were a statistically significant association with the attitude.

The study indicated that knowledge of women toward the legalization of abortion was low but more than half of respondents prefer abortion on demand to be legalized.

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Plain English summary

Unsafe abortion contributes about 13% of the global burden of maternal mortality and up to 25–35% of maternal deaths in Ethiopia. Sixty nine percent of Ethiopian women who experienced termination of pregnancy used unsafe abortion practices.

The aim of this study was to assess the knowledge and attitude of women towards legalization of abortion and its associated factors. The data were collected voluntarily and women who were critically ill, unable to talk or listen were excluded from the study. To measure knowledge; first, we asked whether women were aware the current abortion law of Ethiopia; if they answered yes, we continued to ask the legal prerequisites in Ethiopia to interrupt pregnancy. Knowledge of women toward the legalization of abortion was measured by seven closed-ended questions. The answers for the seven questions were aggregated out of seven. Those respondents who score above the median knowledge level (median knowledge score = 4) were considered as having good knowledge and those who score less than the median score were classified as having poor knowledge toward abortion legislation.

The attitude of women toward abortion legislation was measured by asking five closed-ended questions with both positive and negative responses. Those women who agreed or answer positively, considered as positive attitude and those respondents disagreed or negatively responded were considered as a negative attitude.

Of the 576 respondents: only 23.4% of women have good knowledge and 56% prefer abortion on demand to be legalized. Forty-three percent of women do not want to use the service even if it was legalized. And, 53.3% of women don’t think that women would have the right to use the service even if the pregnancy fulfills the legal criteria. Knowledge of abortion legislation differs among ethnic group, marital status, and households with different family size. Again, level of education, marital status, and knowledge of women about legislation of abortion were the associated factors for the attitude of women.

In conclusion, knowledge of women toward the legalization of abortion was low but more than half of respondents prefer abortion on demand to be legalized.

Maternal mortality is a public health problem in the world, especially in developing countries. Each year more than half a million maternal death happen in the world. From this, 99% occur in developing countries [ 1 ]. Sub Saharan Africa and South Asian alone accounts for 84% global maternal deaths [ 2 , 3 ]. There are many factors contributing to maternal deaths, from these hemorrhages, infection during and after delivery and also unsafe abortion are among the leading cause of maternal death [ 4 ]. Unsafe abortion alone contributes about 13% of the global burden of maternal mortality [ 5 ]. According to World Health Organization, every year greater than 42 million pregnancies are terminated due to various reasons; from that, approximately 20 million are due to unsafe abortions and it is estimated about 80, 000 worldwide deaths from it [ 6 , 7 ].

In Ethiopia, the number of maternal deaths associated with complication of pregnancy and delivery is among the highest in the world [ 5 ]. In Ethiopia, the ratio of maternal mortality (MMR) is 412 per 100,000 live births [ 8 ]. Several studies indicate that unsafe abortion accounts for up to 25–35% of maternal deaths in Ethiopia [ 9 , 10 ]. Unsafe abortion complication found to be significant public health problems in Ethiopia, accounting for the higher proportion of maternal morbidity, mortality and gynaecological admissions [ 7 ]. It can be prevented and reduced by expanding and improving family planning services and choices. With a low modern contraceptive prevalence rate (4.8%) and a high total fertility rate (6.8–7%), a large number of Ethiopian women faced unwanted pregnancies [ 5 ]. Sixty nine percent of Ethiopian women who experienced termination of pregnancy used unsafe abortion practices rather than medically supervised abortion [ 2 , 5 ]. The reason behind might be the lack of knowledge and attitude of women toward the legalization of abortion.

Ethiopia amended abortion law in May 2005 under certain conditions. Abortion is now legal in cases of rape, incest or fetal impairment. In addition, a woman can legally terminate a pregnancy if her life or physical health is in danger, if she has physical or mental disabilities, or if she is a minor who is physically or mentally unprepared for childbirth [ 9 , 11 , 12 ].

Knowledge about abortion law among women is very important because it has implications for access to legal abortion services [ 13 ]. As outlined in the WHO guideline on safe abortion, the proportion of women with correct knowledge of the legal status of abortion are both indicators for measuring access to information about safe abortion [ 14 ]. Even when safe, legal abortion services are available, women who lack accurate information about the law may seek unsafe abortion because they do not know that they are eligible for the service or do not know the legal requirements for obtaining an abortion [ 15 ]. Knowledge alone is not guarantee to use any service; but the attitude determines.

Research on knowledge of abortion law and attitude of women towards the law may help to inform policy makers and education planners in Ethiopia. Unfortunately, not much research has been conducted in this area among the women in the country. The aim of this study was to investigate knowledge and attitude of women toward the abortion law. Furthermore this study also identifies the associated factors influencing knowledge and attitude of women toward the legalization abortion.

Study design and setting

A community based cross-sectional study design was conduct from January 02 to 17, 2017 in Arba Minch town. The Town is found 465 km from Addis Ababa (the capital city of Ethiopia) to the south. The town has 11 kebeles (the lower administrative unit of Ethiopia). According to population projection of the 2007 national census conducted by the central statistics agency of Ethiopia (CSA), there was an estimated population of 110,104 of whom 53,951 were men and 56,153 were women. From this, 21,360 were reproductive age women. There were 19,000 households in the town during the data collection period.

Study participants

The study population was women in reproductive-age who were living in the town for more than six months in the randomly selected kebeles of the town. The data were collected voluntarily and women who were critically ill, unable to talk or listen were excluded from the study.

Sample size and sampling method

The required sample size was determined using a single population proportion formula. The assumptions considered were; proportion (p) of 50%, a margin error of 5%, a design effect of 1.5 and none response rate of 10%. Accordingly, the sample size was: n = (1.96) 2 × 0.5 (1–0.5)/ (0.05) 2 ; n = 384, and by considering 10% no response rate and a design effect of 1.5 the total sample size was 633. A multistage sampling technique was used. Five kebeles out of 11 kebeles were randomly selected using the lottery method. List of reproductive age women was extracted from a community-based intervention for action (CBIA) data in the selected kebeles which were collected by health extension workers. The calculated sample size was proportionally allocated to each kebele. To have individual study subjects, systematic sampling method was employed during data collection with K value of 4 ( N = 2591 and n = 633 i.e. every 4th from the registration). The first woman was selected by lottery method.

Data collection procedure

Data were collected using field-tested structured questionnaire. The questionnaire was developed after reviewing related literatures. The questionnaire has different sessions such as socio-demographic characteristics of respondents, 7 abortion history items, 5 attitude items and 7 items on knowledge questions. The questionnaire prepared in English was translated to Amharic (local language) and back to English in order to maintain consistency. Five data collectors those speak the local language (Amharic) collected the data with two supervisors.

Data analysis

Data were entered into EpiData v3.1, exported to SPSS version 21 and cleaned to check for completeness and missing values. Descriptive statistics such as frequencies and summary statistics were used to describe the study population in relation to relevant variables. In binary logistic regression, both bivariate and multivariate analyses were carried out. All variables were entered into the bivariate analysis to identify the association between dependent and independent variables. Those explanatory variables with a p -value < 0.25 in the crude analysis had been used for multivariate analysis. In multivariate analysis, those variables with the p-value < 0.05 were considered as predictors of the legalization of abortion care.

Measurements

Knowledge of abortion legalization was measured by asking seven abortion legislation questions. Questions were developed based on reviewing the Ethiopian legislation for abortion and other similar studies [ 10 , 16 , 17 , 18 ]. First, women asked whether they aware about the current abortion law of Ethiopia; if the woman answered yes, we continued to ask the legal prerequisites in Ethiopia to interrupt pregnancy to know their knowledge level. To assess knowledge of the abortion law, seven closed-ended questions were used. The answers for these seven questions were aggregated out of seven. Those respondents who score above the median knowledge level (median knowledge score = 4) were considered as having good knowledge and those who score less than the mean score were classified as having poor knowledge of abortion legislation.

The attitude of women toward abortion legislation was measured by asking five closed-ended questions with both positive and negative responses. Those women who agreed or answer positively, considered as a positive attitude and those respondents disagreed or negatively responded were considered as a negative attitude.

Data quality management

The questionnaires were pretested outside the study area. After the pretest, the questionnaire was reviewed for appropriateness of wording; clarity of both contents and whether instructions elicited is going with responses. Data collectors were trained for one day to be familiar with the data collection tool. Editing and sorting of the questionnaires were done to determine the completeness and consistency of data every day during the data collection. The completed questionnaires were cross-checked and made a correction on daily basis.

Socio-demographic characteristics

A total of 576 women were interviewed from five kebeles. The overall response rate was 91%. One hundred sixty seven (29%) of the respondents were in the age group of 35–39 with the mean age of 34.48 + 5.43. Forty-five percent of women were Gamo in ethnicity while 27.9% were Konso. One hundred sixty six (28.9%) of study participants were attended primary school. Two hundred sixty two (45.6%) and 246 (42.7%) were followers of protestant and Orthodox religions, respectively. Two hundred forty seven (69%) of the mothers are currently living with their husband. One hundred seventy-three (30%) of the study participants were government workers. Two hundred thirty two (40.4%) of the respondents earn monthly income of greater than 1500 Ethiopian Birr (27 Ethiopian Birr = 1 USD). Three hundred eighteen (55.2%) of the respondents had family size of 3–6 (Table 1 ).

Abortion history

Among women included in the study 476(82.6%) had ever pregnant while 159(27.6%) had the history of unwanted pregnancy. One hundred twenty five (21.6%) of respondents have had induced abortion. From the total study participants about ninety two (73.5%) use private health institution as the place of abortion. Two hundred seventy one (47.1%) of women want to continue if they had unwanted pregnancy; while 158 (27.6%) women desire to terminate. Among the respondents, 372 (64.6%) were using family planning (Table 2 ).

The attitude of women toward legalization of abortion

Among women included in the study 323(56%) prefer abortion on demand to be legalized while 241 (41.9%) do not prefer to be legalized. Out of the respondents 327 (56.8%) were think that if abortion is legally allowed people can use the service. Three hundred forty (59%) of respondents do not use the service by themselves if abortion is legally allowed and 308(53.4%) also do not think that woman have the right to terminate their pregnancy. Two hundred seventy (46.8%) do not agree if women decided for some reason to terminate their pregnancy (Table 3 ).

Knowledge of respondents toward legalization of abortion

Among the women included in the study 187 (32.5%) had ever heard about safe abortion while 389(67.5%) had none. Out of respondents who had ever heard about save abortion 107(19%) were heard from their friends. Three hundred ninety six (69%) of respondents didn’t know about the complication of abortion while only 180(31%) knew. From the respondents only 135(23.4%) of women knew whether abortion was legal in Ethiopia but, majorities (67%) of respondents did not knew. From those respondents who knew about legalization of abortion in Ethiopia, 108(80%), 80(59%), 114(84.4%) and 18(13%) mentioned that abortion is legal if it is by incest, has a problem on mother; by rape and mother didn’t want respectively. One hundred seventeen (86.7%) of respondents believe that abortion was decided by women themselves while 18(13.3%) of them by doctor /health professionals. According to 93(69%) of respondents the time of abortion was before 3 months of pregnancy (Table 4 ).

Factors associated with attitude toward legalization of abortion

All predictors of attitude toward legalization of abortion were entered into a logistic regression model and the final associated factors were identified. From those entered into the model, marital status, educational, pregnancy termination history and knowledge were statistically significant that affect the attitude of women toward legalization of abortion. The study revealed that single women and divorced were 81.9 and 93.1% times less likely had a good attitude as compared to married (Adjusted Odds Ratio (AOR) = .181, 95% Confidence Interval(CI): 0.377–0. 087) and (Adjusted Odds Ratio (AOR) =0.069, 95% Confidence Interval(CI): 0.062–0.460) respectively.

The attitude toward legalization of abortion among women who attend primary school was 3.666 times (AOR = 3.666, 95% CI: 1.772–7.581) and 3.431 times (AOR = 3.431, 95% CI: 1.083–10.87) more likely compare to those who attended higher education. Again, those who were illiterate and read & write were 4.804 and 11.258 times more likely good attitude than higher education (AOR = 4.804 and 11.26, 95%CI:1.453, 15.881 and 4.49, 28.227) respectively. Knowledge is a factor for attitude toward legalization of abortion. Those who answer, currently abortion on demand is illegal in Ethiopia 77.6% times (AOR = 0.224, 95% CI: .123–.409) less likely had a good attitude than those who answered I don’t know. But those who know abortion on demand is legal in Ethiopia were 1.84 times (AOR = 1.84, 95% CI: 1.137–2.976) more likely good attitude than those who don’t know (Table 5 ).

Factors associated with knowledge toward legalization of abortion

All predictors of knowledge toward legalization of abortion were entered into a logistic regression model and the final associated factors were identified. From those entered into the model, marital status, ethnicity and family size were statistically significant for knowledge. The knowledge of women who were Konso, Wolaita and those who were other in ethnicity was 93, 86 and 95.3% less likely more knowledgeable about the legalization of abortion compared to women who were Gamo in ethnicity respectively. The study revealed that single women were about 95.5% times (AOR = .045, 95% CI: .013–0. 158) less likely good knowledge as compared to married women and also the knowledge among divorced were 99.2% times (AOR = 0.008, 95% CI: 0.002–0.040) less likely compared to who married. Similarly, women who have less than 3 and more than 6 children were about 71.5 and 59.6% times (AOR = 0.285, 95% CI: 0.145–0.561) and (AOR = 0.404, 95% CI: 0.174–0.939) less likely had knowledge than those who have 3–6 children respectively (Table 6 ).

The finding of our study showed that knowledge of women toward legalization of abortion was 23.4% which is low. The result was lower than study done in other part of the country. The study from Harari town revealed that about 35.7% of female students have knowledge towards the legislation of abortion. Again, the finding was much lower than the study done in Debra Markos hospital which was 92% [ 1 ]. Also, lower than the study conducted in other countries. The result was lower than study result in South Africa and Armenia which was 32% in South Africa [ 19 ] and 31% of women knew that, abortion is legal under any condition in Armenia [ 13 ]. The possible difference might be the difference in socio economic condition. But, the finding of this study was higher than study done in Zambia and Nepal. In Zambia the result was 16% [ 11 ]. In Nepal, from 1100 rural married women, only 15% knew about abortion law [ 13 ]. These findings clearly showed that the majority of women did not get information on their own affairs. Lack of knowledge is the result of lack of information. The causes of lower knowledge in the study area might be due to poor information dissemination to the target community. The result of systematic review showed that women who have knowledge of the legal status of abortion were less than 50% [ 20 ]. But, a study done in Latvia showed that more than half (53%) of women knew about the legalization of abortion [ 10 , 19 , 21 ]. In contradiction, this result was much higher than study done in Mizan Aman town of Ethiopia which was only 5.7% knew about the legalization of abortion [ 22 ]. This might be due to information dissemination problem throughout the country.

From those women who have good knowledge on the legalization of abortion majorities (84%) and (80%) of them believe it is legal if pregnancy was from rape/incest and from relative respectively. More than half (59%) of women, believes abortion is legal if it has problem on mothers as well as only 13% believe it is legally allowed for the mother if she don’t want.

Concerning the attitude of women; more than half of the respondents had a good attitude toward the abortion legalization while 42% do not. The result was consistent with the study done in the Mizan Aman town in which the attitude of women toward the legalization of abortion was 54.4% [ 22 ]. But, the result was somewhat higher than study done in Armenia and Debra Markos hospital which was 30 and 23% respectively [ 1 , 13 ]. This difference might be due to the reality of the problem in the community. In Ethiopia, act of abortion has condemned almost by all religion and cultures. But, condemnation alone might not bring solution. More than half (57%) of the participants believe if service become legal, women can use the service but, 59% of women don’t think they will use by themselves even if abortion would be legal in Ethiopia. Almost half (53.3%) of respondents don’t think that women would have the right to terminate their pregnancy if the pregnancy fulfills the criteria. Again about 47% do not agree if women decided to terminate their pregnancy in any case. Therefore, the result showed that the majority (56%) of women had a positive attitude toward the legalization of abortion; but still large proportion of women have negative attitude toward the legalization of abortion. This perception of the community shows still need an intervention. In Ethiopia, since 2004 abortion has been legalized under some circumstances. But only less than 6% used public health facilities and about 73% uses private clinics in this finding; the possible reason might be the low knowledge and problem related to the attitude. Changing community knowledge and attitudes might be challenging; particularly when the topic is stigmatized. Additional intervention be needed to improve access to safe abortion service and other reproductive services for women at the community level.

Nearly 40 years after India legalized abortion, Indian women continue to be unaware that safe abortion service was given at public health facilities or was unable to access it. Although abortion has been legal in India for decades, unsafe abortions were estimated to be 90% [ 18 ]. The underlying reason might be the attitude related to the issue. In our case, East Africa, in particular, has one of the world’s highest rates of maternal mortality linked to complications from unsafe abortions. Over 50% of all women seeking abortions in Ethiopia do so outside the reach of trained medical professionals and outside of health facilities even after the legalization of safe abortion service [ 6 ]. The reason might be due to stigma and the wrong belief of the community toward abortion which enforces women to choose secrecy over safety.

In our study, ethnicity, marital status and family size were the socio demographic factors significantly associated with knowledge. For attitude, marital statuses, level of education as well as knowledge were associated factors. The same with the study done in Debra Markos hospital and Mizan Aman town where the knowledge was the associated factors [ 1 , 22 ].This result was in line with the study done in Harari and Zambia; where age, religion and marital status were a factor, but in our study age and religion were not significant [ 11 , 21 ]. But, accessibility to abortion service was a factor for legalization of abortion in Zambia but not in our case [ 11 ]. Again study done in Mizan Aman town, the preference of termination was a factor for the knowledge of abortion; but here in our study it was not an associated factor [ 22 ].

The study showed that educational status, marital status and having knowledge about the legalization of abortion has a statistically significant association with an attitude. The result was in line with the study conducted in Mizan Aman town and Yirgalem south nation nationality of Ethiopia and other parts of Africa [ 11 , 12 , 19 ].

In conclusion, our study indicated that knowledge of women about the legalization of abortion was low and more than half of women had positive attitude to the legalization of abortion. But, still immense proportion of women (42%) have negative attitude toward the legalization of abortion. Moreover, Ethnicity, marital status, and the number of children were strong predictors of knowledge while education, history of pregnancy termination and knowledge were the predictor of attitude toward legalization of abortion. Thus, it was recommended that the concerned body should give attention to awareness creation and give comprehensive health education and information should be given on a local basis.

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Acknowledgments

We are grateful to acknowledge our study participants for providing the necessary information and the data collectors for collecting the data carefully.

The data collection process of this study was funded by the Arba Minch University for the support of the data collection. The funding body only followed the process to confirm whether the fund allocated was used for the proposed research.

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Tilahun Fufa Debela

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Misgun Shewangizaw Mekuria

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Debela, T.F., Mekuria, M.S. Knowledge and attitude of women towards the legalization of abortion in the selected town of Ethiopia: a cross sectional study. Reprod Health 15 , 190 (2018). https://doi.org/10.1186/s12978-018-0634-0

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Abortion Experiences, Knowledge, and Attitudes Among Women in the U.S.: Findings from the 2024 KFF Women’s Health Survey

Ivette Gomez , Karen Diep , Brittni Frederiksen , Usha Ranji , and Alina Salganicoff Published: Aug 14, 2024

Methodology

Key Takeaways

Among women of reproductive age, one in seven (14%) have had an abortion at some point in their life. Larger shares of Black (21%) and Hispanic (19%) women report having had an abortion compared to 11% of White women. Across partisanship, similar shares of Republican women, Democratic women, and independents report having had an abortion.
Nearly one in ten (8%) women of reproductive age personally know someone who has had difficulty getting an abortion since Roe v. Wade was overturned, including 11% of Hispanic women and 13% of women living in states with abortion bans.
Among women of reproductive age who report knowing someone personally who has had difficulty getting an abortion since Roe v. Wade was overturned, many say they had to travel out of state for care (68%), did not know where to go (40%), and/or did not have the money to cover the cost (35%).
More than six in ten women of reproductive age are concerned that they, or someone close to them, would not be able to get an abortion if it was needed to preserve their life or health (63%) and that abortion bans may affect the safety of a potential future pregnancy for themselves or someone close to them (64%).
Less than half of reproductive age women in the United States are aware of the current status of abortion policy in their state (45%). Nearly a quarter describe the status incorrectly (23%) and a third are unsure about the status of abortion in their state (32%).
One in four (26%) reproductive age women say if they needed or wanted an abortion they would not know where to go nor where to find information.
Nearly one in five women (17%) of reproductive age report they have changed their contraceptive practices as a result of Roe being overturned. Actions taken include starting birth control, getting a sterilization procedure, switching to a more effective method, or purchasing emergency contraceptive pills to have on hand.
While two-thirds of women have heard about medication abortion pills, only 19% of women say people in their state can get medication abortion pills online.
Three in four reproductive age women in the United States think abortion should be legal in most or all cases (74%). The majority support a nationwide right to abortion (70%), oppose a nationwide abortion ban at 15 weeks (64%), and oppose leaving it up to the states to determine the legality of abortion (74%). This is the case for the majority of women who are Democrats and independents as well as smaller but still substantial shares of Republicans.

Introduction

In the two years since the Dobbs decision, which overturned Roe and eliminated the federal standards that had protected the right to abortion for almost 50 years, the abortion landscape in the United States has drastically changed. Abortion is banned in 14 states and an additional six states have implemented early gestational limits between 6 and 15 weeks.

Abortion will likely be a key issue in the upcoming 2024 election . The Democratic and Republican parties have starkly different visions of what access to abortion in the U.S. should look like. Vice President and Democratic Nominee Kamala Harris has been an outspoken advocate of abortion rights and has thrown her support behind efforts to restore Roe v. Wade’ s abortion standards in all states. Former President Donald Trump endorses leaving abortion policy up to states, allowing full bans to stay in effect, although he has also previously said he would consider a 15 or 16-week national ban on abortion. At the state level, voters in up to 11 states will vote on abortion-related ballot initiatives that will shape access to abortion in their states.

This brief provides new information about women’s experiences with abortion, the fallout of overturning Roe v. Wade , women’s knowledge about abortion laws in their states including medication abortion, as well as their opinions on the legality of abortion. The 2024 KFF Women’s Health Survey was fielded from May 15 to June 18, 2024, before President Biden withdrew from the 2024 Presidential race, and was developed and analyzed by KFF staff. It is a nationally representative survey of 5,055 women and 1,191 men ages 18 to 64, and the findings in this brief are based on a sample of 3,901 women ages 18 to 49. See the methodology section for detailed definitions, sampling design, and margins of sampling error.

Women’s Experiences With Abortion

Among women of reproductive age, one in seven (14%) report having had an abortion at some point in their life. Larger shares of Black (21%) and Hispanic (19%) women report having had an abortion compared to 11% of White women ( Figure 1 ). A higher share of women with lower incomes had an abortion (17%) compared to women with higher incomes (13%).

Smaller shares of women living in rural areas report having had an abortion compared to those living in urban/suburban areas (7% vs. 15%, respectively). Many rural women face long travel distances to access abortion services.

Similar shares of Republican women (12%), independent women (15%), and Democratic women (14%) say they have had an abortion. Throughout this brief, partisans include independents who lean to either party, while independents are individuals who say they do not lean toward either political party. Nearly one in 10 women (8%) who currently identify as pro-life say they have had an abortion compared to almost one in five (17%) who currently identify as pro-choice.

Smaller shares of women living in states with abortion bans or gestational limits between 15 and 22 weeks have had an abortion compared to women living in states with gestational limits at or after 24 weeks or without any gestational limits. Even before the Dobbs decision, abortion access was very limited in many of the states that currently ban abortion or have gestational limits before viability. Most of these states had laws restricting access to abortion, including waiting periods, counseling and ultrasound requirements, and insurance coverage restrictions which resulted in the closure of many abortion clinics in the years preceding the Dobbs decision.

Among women who say they have ever wanted or needed an abortion, 15% (2% of all reproductive age women) report that at some point in their lives, they have wanted or needed an abortion that they did not get ( Figure 2 ). A larger share of Black women (24%) (5% of all Black women of reproductive age) who have ever been pregnant and have wanted or needed an abortion report that they have wanted or needed an abortion they did not get compared to White women (12%) (1% of all White women of reproductive age). When asked why they did not get a wanted or needed abortion, a third (33%) report access and affordability issues, with affordability issues making up the majority of the category. One in five women also identify religious, moral, or societal pressures as the reason why they did not get the abortion, and another 16% say they changed their mind or couldn’t go through with the abortion. One in 10 women say they were too far along to end the pregnancy. Among the women who report ever wanting or needing an abortion they did not get, 31% say they had an abortion at some other time (data not shown).

In their own words: There are many reasons why someone may not get an abortion. What was the reason you did not get the abortion(s)?

“Unable to afford the procedure and would be reaching [the] point where it would be too late to complete if able.”

“Was a day over the amount of days in order to have an abortion. I waited too long to get it.”

“Changed my mind. Decided to keep the baby but was initially scared and unsure of what to do.”

“I decided I wanted to keep and raise my child despite societal pressures that would advise against it (I was a minor).”

“My family made me feel like I couldn’t and I was scared so I followed through with my pregnancy.”

“I was intimidated by the child’s father showing up at the clinic.”

“I could not afford to go out of state and had no way out of [the] state.”

“Ended up miscarrying before proceeding with appointment.”

“I was too far along in the pregnancy when I found out I was pregnant”

“Religious reasons. We are Catholic and it’s not an option for us.”

“The service wasn’t easily accessible to me, and my partner’s family pressured me into having the child.”

“Guilt, moral compass”

“Nurse convinced me not to get it.”

“I could not afford it at the time and unsure if I really wanted to do it.”

“Family pressure, difficulty finding a place to perform an abortion.”

“I lived an hour and a half from the location and my ride didn’t show up.”

The Impact of Overturning Roe

Two years after the Supreme Court overturned the constitutional right to abortion, 14 states have banned abortion, and 11 states have implemented gestational restrictions between 6 and 22 weeks LMP (last menstrual period). Nationally, 8% of reproductive age women say they personally know someone, including themselves, who has had difficulty getting abortion care since Roe was overturned due to the restrictions in their state ( Figure 3 ). Larger shares of Hispanic women (11%) than White women (8%) report knowing someone who has experienced difficulty getting an abortion. Similarly, larger shares of women living in states with abortion bans (13%) and women living in states with gestational limits between 6 and 12 weeks (11%) report knowing someone who has experienced difficulty compared to women living in states with gestational limits at or after 24 weeks or without gestational limits (6%). Even in states with few abortion restrictions, access to abortion services can be limited by lack of providers, poor coverage, and other factors.

Among those who say they know someone (including themselves) who had difficulty getting abortion care since Roe was overturned, the majority report they (or the person they knew) had to travel out of state (68%) ( Figure 4 ). Women with higher incomes who say they or someone they know had difficulty accessing abortion care are more likely to report that they or the person they know had to travel out of state compared to women with lower incomes (75% vs. 62%). Many abortion patients living in states with abortion bans or restrictions have to travel to neighboring states to get abortion care, while others may need to travel farther .

Among women who say they or someone they know had difficulty accessing abortion, four in ten women say they or a person they know did not know where to go when trying to get an abortion (40%), three in ten women say they could not afford the cost (35%), and nearly three in ten say they had to take time off work (28%).

When asked about women’s ability to get abortion services in their state, more than half of women residing in states with abortion bans (57%) and over four in ten women in states with gestational limits say it is difficult to access abortion care in their state (Figure 5). Notably, one in five (21%) women residing in states with gestational limits at or after 24 weeks or without gestational limits say it is difficult to get abortion services in their state. While abortion may not be restricted, limitations on Medicaid and insurance coverage of abortion, the scarcity of abortion providers in rural communities, stigma, and other factors (such as the need to take time off from work and childcare costs) are still barriers to abortion.

O ver six in ten reproductive age women in the U.S. (63%) are concerned that they or someone close to them would not be able to get an abortion if it was needed to preserve their life or health (Figure 6). While all states with abortion bans and abortion restrictions have an exception in their law to “prevent the death” or “preserve the life” of the pregnant person, six states with abortion bans or early gestational restrictions do not have health exceptions. In general, health exceptions have often proven to be unworkable except in the most extreme circumstances. The abortion policies in these states are generally unclear about how ill or close to death a pregnant person would have to be to qualify for the exception.

With the exception of Republican women, a majority of reproductive age women in all subgroups report that they are very or somewhat concerned about access to abortion if it was needed to preserve their life or health. Larger shares of Asian or Pacific Islander women (75%) than White women (61%) are concerned, and smaller shares of women residing in rural areas (52%) are concerned compared to those residing in urban/suburban areas (65%). Compared to Democratic women (78%), smaller shares of women who identify as independent (61%) are concerned that they or someone close to them would not be able to get an abortion if it was needed to preserve their life or health; however, less than half of Republican women report being somewhat or very concerned (41%).

Similarly, over 6 in 10 (64%) reproductive age women say they are concerned that abortion bans may affect the safety of a potential future pregnancy for themselves or someone close to them ( Figure 7 ). Across most subgroups—except across party affiliation— majorities of women say that they are somewhat or very concerned. Four in ten (39%) Republican women say they are concerned about the impact of abortion bans on the safety of potential pregnancies for themselves or someone close to them, compared to almost eight in 10 Democratic women and six in 10 independent women.

Nearly one in five women (17%) of reproductive age report they have changed their contraceptive practices as a result of Roe being overturned. Larger shares of Asian or Pacific Islander, Black, and Hispanic women report they started to use birth control (9%, 10%, and 7%, respectively) compared to White women (3%) ( Table 1 ). A higher share of Asian or Pacific Islander women report that they have switched to a more effective method of birth control compared to White women (6% vs. 3%), and 7% of Hispanic women report that they have gotten emergency contraception to have on hand compared to 4% of White women.

Awareness of Abortion Availability and Policy

Nationally, most women of reproductive age are unaware of the status of abortion legality in the state they live in. While 45% can correctly describe the status of abortion in their state, 23% of reproductive age women could not answer correctly and another third (33%) say they are not sure ( Figure 8 ). Awareness is highest among women who live in states where abortion is fully banned (51%) or in states with gestational limits at or after 24 weeks or without bans (47%). Smaller shares of women living in states with gestational limits at 15 to 22 weeks (33%) and limits at 6 to 12 weeks (38%) are aware of the status of abortion in their state. Consistently across state abortion groupings, about a third of women say they are not sure on the status of abortion in their state.

One in four (26%) women of reproductive age in the U.S. report that if they needed or wanted an abortion in the near future they would not know where to go or where to find the information (Figure 9). A quarter of women say they would know where to go for an abortion and half (49%) say they would not know where to go, but would know where to find that information. Since the Dobbs decision, websites like abortionfinder.org and ineedana.com provide individuals seeking abortion services with directories of abortion clinics and services that provide medication abortion via telehealth.

Over a third of Hispanic women (37%) and a third of Black women (33%) report that if they wanted or needed an abortion in the near future, they wouldn’t know where to find information compared to 23% of White women. More women with lower incomes (37%) and women living in rural areas (35%) report they wouldn’t know where to go or find that information compared to women with higher incomes (19%) and women living in urban/suburban areas (25%). Over four in 10 (43%) women living in states where abortion is banned say they wouldn’t know where to find information compared to 17% of women in states with gestational limits at or after 24 weeks or without gestational limits. Women living in banned states seeking abortion services must either travel out of state or obtain medication abortion drugs from companies that will ship pills without requiring a clinician visit or from clinicians practicing in states with shield-laws, which offer clinicians a measure of legal protection from attempts by law authorities in abortion ban states to enforce bans in states that support abortion access.

In the United States, medication abortion is the most common abortion method. It involves taking two different medications, mifepristone and misoprostol, and it has been approved by the FDA to end pregnancies up to 10 weeks gestation. Two-thirds (67%) of women of reproductive age report that they have heard about medication abortion ( Figure 10 ). While still majorities, relatively smaller shares of Asian or Pacific Islander (62%), Black (64%), and Hispanic (59%) women report having heard about medication abortion compared to White women (72%). Similarly, smaller shares of women with lower incomes (60%) have heard about medication abortion compared to women with higher incomes (74%). Compared to women who identify as pro-choice (72%) and women who are Democrats (77%), smaller shares of women who identify as pro-life (56%) or are Republican/Republican leaning (62%) or independents (60%) report hearing of medication abortion.

The majority of women are unsure of the legal status of abortion in their state. While neither mifepristone nor misoprostol are explicitly banned in any state and the drugs can still be used for miscarriage management treatment, their use for abortion is banned in the 14 states with abortion bans. Medication abortion, for the purposes of abortion, is legal in all states with gestational restrictions as well as states without any limits, but is not legal to use for abortion after the state’s gestational limit (for example, after 6 weeks LMP in Iowa, Florida, Georgia, and South Carolina).

The majority of women of reproductive age are unclear about the legal status of medication abortion in their state, regardless of the legal status of abortion in their state ( Figure 11 ). A larger share of women living in states with gestational limits at 24 weeks or without gestational limits (43%) report that medication abortion is legal in their state compared to women living in states with gestational limits between 6 to 12 weeks (19%) and gestational limits between 15 to 22 weeks (18%). Among women living in states where abortion is banned, 6% say medication abortion is legal in their state and 27% say it is illegal. Regardless of the status of abortion in their state of residence, majorities of women of reproductive age are not aware of the legal status of medication abortion in their state or have never heard of medication abortion.

Overall, only one in five (19%) women of reproductive age are aware that medication abortion pills are available online. Since state abortion bans and restrictions have gone into effect, new online services have been created that sell medication abortion pills through online organizations. Among women of reproductive age, 10% say individuals in their state cannot get medication abortion pills online and about three-quarter (71%) were unsure or had never heard of medication abortion ( Figure 12 ). Small shares of women living in states where abortion is banned or states with gestational limits know that people in their states can get medication abortion pills online compared to women living in states without any gestational limits or limits after 24 weeks.

Opinions on Abortion Policy

Three in four (75%) women of reproductive age in the United States, the age group that is most directly impacted by state abortion policies, think that abortion should be legal in most or all cases—38% say legal in all cases and 37% legal in most cases. Only 8% of women say that abortion should be illegal in all cases. This trend is consistent with prior polls which have found that the majority of Americans believe that abortion should be legal.

Across various subgroups, except those who identify as Republican or pro-life, majorities of reproductive age women think abortion should be legal in all or most cases. Among those ages 18 to 49, over eight in 10 Black women (83%) and Asian or Pacific Islander women (83%), and almost three-quarters of Hispanic women (73%) and White women (72%) think abortion should be legal ( Figure 13 ). In contrast, slightly less than half (48%) of Republican women of reproductive age think abortion should be legal, 36% say abortion should be illegal in most cases and 17% say abortion should be illegal in all cases. Not surprisingly, among women who identify as pro-life, 74% say that abortion should be illegal in all or most cases, but one in four (25%) believe that abortion should be legal in all or most cases.

Seven in ten reproductive age women (70%) support a law guaranteeing a federal right to abortion, with half (50%) saying they strongly support this (Figure 17) . While similar shares of Asian, Black, Hispanic, and White reproductive age women support a nationwide right to abortion, support varies widely by income, urbanicity, and party affiliation ( Figure 14 ). Though still a majority, smaller shares of reproductive age women with lower incomes (64%) and women who live in rural communities (62%) support a nationwide right to abortion compared to their urban/suburban (71%) and higher income counterparts (74%). Support is strongest among Democratic (84%) women, but two thirds (64%) of women who identify as independents and nearly half of Republican women (48%) strongly or somewhat support establishing a federal right to abortion. More than three times as many Democrats (71%) than Republicans (22%) strongly support a law that would guarantee this right.

More than half of all women of reproductive age support a law establishing a nationwide right to abortion, regardless of the abortion status in their state of residence. While there are smaller shares of support among women who reside in states with bans and gestational limits before viability, over four in 10 women in these states strongly support a law guaranteeing a federal right to abortion.

On the issue of abortion, former President Trump has previously said he would consider a national ban at 15 or 16 weeks, a position also proposed by other Republican elected officials. Overall, six in ten women of reproductive age (63%) oppose a law that would establish a nationwide ban on abortion at 15 weeks ( Figure 15 ). While still a majority, smaller shares of those with lower incomes (58%) and those who reside in rural areas (55%) oppose a national abortion ban at 15 weeks. Six in ten women in states with abortion bans and gestational limits before viability oppose a national ban on abortion at 15 weeks.

Most recently, former President Trump announced he supports leaving abortion policy up to the individual states, allowing the current bans and restrictions to stay in effect across half the country. Overall, nearly three in four women of reproductive age (74%) oppose this approach ( Figure 16 ). Similar shares of Asian (72%), Black (75%), Hispanic (75%), and White (72%) reproductive age women oppose leaving abortion policy up to the states. Compared to their counterparts, larger shares of women with higher incomes (76%) and those who live in urban/suburban communities (74%) oppose having states decide whether abortion should be legal or illegal in their states.

At least half of all women oppose this approach regardless of party affiliation, but opposition is highest among Democratic women (88%). While there is slight variation in support/opposition by abortion status in a woman’s state of residence, over two thirds of those in states with abortion bans and gestational limits oppose leaving the legality of abortion up to individual states.

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Is Abortion Law in the US Changed Forever?

by Karen Nikos-Rose
October 04, 2023

Late June marked the one-year anniversary of Dobbs v. Jackson Woman’s Health Organization, the Supreme Court decision reversing Roe v. Wade. The court’s decision has opened a new chapter in conflicts around reproductive rights and justice, explained Mary Ziegler, Martin Luther King Professor of Law at the UC Davis School of Law. Ziegler, a 2023-24 Guggenheim fellow, researches the legal history of struggles around abortion and other reproductive health issues. Since last year, there have already been six ballot initiative struggles, more than half a dozen state Supreme Court challenges and additional fights in federal court aimed at limiting or even ending access to abortion nationwide.

“A common thread in all this chaos is the tension between voters’ support for legal abortion and new state and federal efforts to take the issue away from voters,” Ziegler said.

Ziegler explained that while the Supreme Court promised that the abortion conflict would be returned to the states, it hasn’t been that simple. Action at the state level has included restrictive legislation across parts of the South and Midwest. More strikingly, Ziegler said, when voters have a chance to separate their preferences about abortion from their partisan affiliation, abortion rights supporters have scored stunning victories, winning six of six ballot initiative fights in states as different as California, Michigan and Kentucky.

The response from those opposed to abortion has been to fight on different terrain: raising the threshold for voters to initiate a ballot measure, for example, or returning to the federal courts.

“The appeal of the federal courts is that they might deliver what voters would never endorse,” Ziegler said. “That’s certainly the case when it comes to passage of a nationwide ban on abortion.”

On the other side, Dobbs sparked hope that Congress might pass a federal law codifying access to abortion and other forms of reproductive health care. Democrats promoted a bill, the Women’s Health Protection Act, that promised to do just that. Others looked for new constitutional arguments based on equality rather than privacy. Eventually, Ziegler said, it’s right to hope that abortion rights — and perhaps other reproductive liberties — will win recognition from the courts. But in the shorter term, struggles over abortion law will more likely turn on whether the status quo remains — where people in states with bans can travel or buy pills online — or whether access to abortion falls away, and with it, access to contraception or even in vitro fertilization.

Additional concerns

In 2022, Ziegler said, states mostly stayed away from the most divisive issues, like bans on birth control or laws that applied abortion bans in other states. But that is no reason for complacency for those that support reproductive rights, even in states like California. Ziegler said that conservative lawmakers recognize how easy it is to circumvent existing bans. That’s the reason some groups opposed to abortion are championing laws that allow lawsuits against anyone who helps a person seeking abortion from a state where the procedure is prohibited.

Ziegler said that the same concern was behind new lawsuits that revive 19th-century law. Courts have not applied the Comstock Act to abortion for decades, Ziegler said, but lawyers opposed to abortion argue that the text of the statute seems to criminalize mailing anything intended or adapted for abortion. “If a federal court agreed with this interpretation, the implications would be stunning,” Ziegler said. “The courts would then be signing off on a ban on all abortions, since every procedure across the country uses drugs or devices sent in the mail.”

The sweep of the Comstock Act would be hard to predict because the interpretation championed by abortion opponents includes items “adapted” for abortion. That could raise new questions about what drugs cause abortion — an issue because some abortion opponents believe birth control pills, IUDs and emergency contraceptives to be abortion drugs. And it might have consequences for drugs that could be “adapted” for abortion, like chemotherapy drugs or even Advil.

Another major case turns on whether the Food and Drug Administration had the authority to approve the abortion pill mifepristone. This case could have far-reaching consequences too, Ziegler explained. “The case would not only change the delivery of abortion services across the country,” Ziegler said. “It would also set a precedent that movements could challenge the approval of drugs they don’t like, even decades after the fact.”

The role of voters and companies

Whatever the federal courts decide, voters, medical organizations and companies have an important role to play, said Ziegler.

For doctors and businesses, expressing a view can sway key decision-makers. Historically, businesses and even leading medical organizations tended to see the abortion issue as politically toxic. That’s starting to change, Ziegler argued, and if business leaders and medical professionals put a thumb on the scale, it might make a difference in both state and federal struggles.

As for voters, abortion will be part of key ballot initiatives in states like Ohio, but it will affect elections to Congress — and the White House in 2024. Ziegler argued that the stakes of elections are now much higher when it comes to abortion. Presidents will not only select new judges but also decide how to interpret the Comstock Act and whether to enforce it. Congress will decide whether to repeal the Comstock Act or even pass protection for reproductive rights.

“The law and politics of reproduction are more inextricably linked than ever,” Ziegler explained. “It will be up to voters to shape what comes next.”

This interview was excerpted from a longer Q&A.

Primary Category

The Impact of Legalized Abortion on Crime

We offer evidence that legalized abortion has contributed significantly to recent crime reductions. Crime began to fall roughly 18 years after abortion legalization. The 5 states that allowed abortion in 1970 experienced declines earlier than the rest of the nation, which legalized in 1973 with Roe v. Wade. States with high abortion rates in the 1970s and 1980s experienced greater crime reductions in the 1990s. In high abortion states, only arrests of those born after abortion legalization fall relative to low abortion states. Legalized abortion appears to account for as much as 50 percent of the recent drop in crime.

Acknowledgements and Disclosures

MARC RIS BibTeΧ

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Published Versions

Dobbs and Democracy

Harvard Law Review, Vol. 137, No. 3, p. 738, 2024

U of Penn Law School, Public Law Research Paper No. 24-41

80 Pages Posted: 9 Aug 2024

Katherine Shaw

University of Pennsylvania - Carey Law School; Yeshiva University - Benjamin N. Cardozo School of Law

Melissa Murray

New York University School of Law

Date Written: January 11, 2024

In Dobbs v. Jackson Women’s Health Organization, Justice Alito justified the decision to overrule Roe v. Wade and Planned Parenthood of Southeastern Pennsylvania v. Casey with an appeal to democracy. He insisted that it was “time to heed the Constitution and return the issue of abortion to the people’s elected representatives.” This invocation of democracy had undeniable rhetorical power: it allowed the Dobbs majority to lay waste to decades’ worth of precedent, while rebutting charges of judicial imperialism and purporting to restore the people’s voices. This Article interrogates Dobbs’s claim to vindicate principles of democracy, examining both the intellectual pedigree of this claim and its substantive vision of democracy. In grounding its decision in democracy, the Dobbs majority relied on a well-worn but dubious narrative: that Roe, and later Casey, disrupted ongoing democratic deliberation on the abortion issue, wresting this contested question from the people and imposing the Court’s own will. The majority insisted that this critique had always attended Roe. However, in tracing the provenance of the democratic deliberation argument, this Article finds more complicated intellectual origins. In fact, the argument did not surface in Roe’s immediate aftermath, but rather emerged years later. And it did so not organically, but through a series of interconnected legal, movement, and political efforts designed to undermine and ultimately topple Roe and Casey. The product of these efforts, the Dobbs majority’s claim that democracy demanded overruling Roe and Casey, was deployed to overcome the force of stare decisis in Dobbs — and may ultimately reshape the scope and substance of the Court’s stare decisis analysis in future cases. Having identified the intellectual origins of the democratic deliberation argument and its contemporary consequences, this Article examines the contours of the Dobbs majority’s vision of democratic deliberation. We show that although Dobbs trafficked in the rhetoric of democracy, its conception of democracy was both internally inconsistent and extraordinarily limited, even myopic. The opinion misapprehended the processes and institutions that are constitutive of democracy, focusing on state legislatures while overlooking a range of other federal, state, and local constitutional actors. As troublingly, it reflected a distorted understanding of political power and representation — one that makes political power reducible to voting, entirely overlooking metrics like representation in electoral office and in the ecosystem of campaign finance. The opinion was also willfully blind to the antidemocratic implications of its “history and tradition” interpretive method, which binds the recognition of constitutional rights to a past in which very few Americans were meaningful participants in the production of law and legal meaning. The deficits of the Dobbs majority’s conception of democracy appear even more pronounced when considered alongside the Court’s recent and active interventions to distort and disrupt the functioning of the electoral process. Indeed, Dobbs purported to “return” the abortion question to the people and to democratic deliberation at the precise moment when the Court’s own actions have ensured that the extant system is unlikely either to produce genuine deliberation or to yield widely desired outcomes. Ultimately, a close examination of the Dobbs majority’s invocation of democracy suggests that the majority may have employed the values and vernacular of democracy as a means to a different end. As we explain, the majority’s embrace of democracy and democratic deliberation allowed it to shield its actions from claims of judicial activism and overreach. More profoundly, and perhaps paradoxically, the opinion may lay the groundwork for the eventual vindication and protection of particular minority interests — those of the fetus. With this in mind, the Dobbs majority’s settlement of the abortion question is unlikely to be a lasting one. Indeed, aspects of the opinion suggest that this settlement is merely a way station en route to a more permanent resolution — the recognition of fetal personhood and the total abolition of legal abortion in the United States.

Keywords: abortion, democracy, reproductive rights, reproductive justice, stare decisis

Suggested Citation: Suggested Citation

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Yeshiva University - Benjamin N. Cardozo School of Law ( email )

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Melissa Murray (Contact Author)

New york university school of law ( email ).

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Survey shows broad opposition to abortion restrictions among women of reproductive age

An protester holds a sign that reads, "Keep Abortion Legal"

The group most directly affected by restrictions on abortion — women of reproductive age — are broadly against them, new survey results have found.

According to findings released Wednesday by KFF, a nonprofit health think tank, 74% of women in the U.S. ages 18 to 49 think abortion should be legal. Around 70% support a federal right to abortion — the position held by Vice President Kamala Harris in a presidential election in which abortion rights are expected to be a motivating factor for many voters.

Nearly half of Republican women of reproductive age said abortion should be legal in most or all cases.

Former President Donald Trump has said states should decide whether abortion is legal , but 74% of the women surveyed disagreed. The figure, however, includes women who instead want a nationwide ban, according to Brittni Frederiksen, an associate director for women’s health policy at KFF who worked on the survey. Around half of the Republican women surveyed who opposed leaving abortion policies up to states took that position, she said.

The findings come from the 2024 KFF Women’s Health Survey, which asked more than 6,200 women ages 18 to 64 across the country about issues such as abortion, contraception and mental health from mid-May to mid-June. The report released Wednesday focuses more narrowly on how women of reproductive age view abortion, based on 3,900 responses.

The results are particularly relevant given the issue’s prominence in the election. Abortion-related measures are on the ballot in eight states, with Arizona and Missouri officially joining the list Tuesday. Similar measures in three other states have the required signatures but are waiting on certification.

A KFF poll conducted in February found that 1 in 8 voters saw abortion as the most important issue in the election and that roughly half considered it very important. A Gallup Poll conducted in May suggested that nearly a third of voters would vote only for a major-ticket candidate who shared their views on abortion.

Trump has recently downplayed the subject, however. He said at a news conference last week that it would be a “very small issue” in the election.

Harris, meanwhile, has emphasized it.

“We trust women to make decisions about their own body and not have their government tell them what to do. And when Congress passes a law to restore reproductive freedoms, as president, I will sign it into law,” she said last month at her first presidential campaign rally .

The choice to have an abortion crosses partisan divides, according to the KFF survey. Roughly similar shares of reproductive-age women from each party reported having had abortions: 12% of Republicans, 14% of Democrats and 15% of independents.

Around 64% said they opposed a nationwide law that would ban abortions after 15 weeks’ gestation. Sen. Lindsey Graham, R-S.C., has proposed such a policy (which would not override more restrictive state laws), and Sen. JD Vance, R-Ohio, Trump’s running mate, signaled support for that bill in 2022. More recently, however, Vance said on CBS News’ “Face the Nation” that he shared Trump’s view that states should determine their own policies.

The broader KFF survey of adults under 65 found that 65% support a nationwide right to abortion, Frederiksen said. A survey the Pew Research Center conducted in April similarly found that 63% of U.S. adults think abortion should be legal in all or most cases.

KFF also released two additional reports Wednesday looking at views on abortion policies among women of reproductive age in Arizona and Florida. Both states have abortion-related measures on their November ballots.

Florida’s measure proposes to overturn the state’s six-week abortion ban , which took effect in May. It needs 60% of the vote to pass.

KFF’s survey results in Florida suggest that 72% of reproductive-age women there think abortion should be legal, including roughly half of Republican women. Still, Frederiksen said, “we don’t know who’s planning on voting and if they’ll show up to vote.”

In Arizona, a key swing state, KFF found that 70% of reproductive-age women think abortion should be legal. More than 6 in 10 said they were concerned that an abortion ban might affect the safety of future pregnancies for them or people close to them.

Abortion is legal in Arizona up to 15 weeks, but in April, the state Supreme Court ruled that an 1864 law banning all abortions except to save a woman’s life was enforceable. Gov. Katie Hobbs later signed a bill repealing the ban before it could take effect.

In the fall, Arizonans will vote on a proposed constitutional amendment that would guarantee abortion care until fetal viability — around the 24th week of pregnancy. A poll in May from CBS News and YouGov indicated that 65% of Arizonans would vote in favor.

Frederiksen said her research shows that many women are unaware of or misinformed about their states’ abortion landscapes. In Arizona, for example, just 58% of reproductive-age women had heard of medication abortion.

“A lot of people just are unaware of the abortion policy in their state, unaware whether medication abortion is legal or not and whether they could get medication abortion pills online,” she said. “So I think there’s a lot of confusion.”

Aria Bendix is the breaking health reporter for NBC News Digital.

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v.19(1); 2017 Jun

Abortion Law and Policy Around the World

Marge berer.

International coordinator of the International Campaign for Women’s Right to Safe Abortion, London, UK, and was the editor of Reproductive Health Matters , which she founded, from 1993 to 2015.

The aim of this paper is to provide a panoramic view of laws and policies on abortion around the world, giving a range of country-based examples. It shows that the plethora of convoluted laws and restrictions surrounding abortion do not make any legal or public health sense. What makes abortion safe is simple and irrefutable—when it is available on the woman’s request and is universally affordable and accessible. From this perspective, few existing laws are fit for purpose. However, the road to law reform is long and difficult. In order to achieve the right to safe abortion, advocates will need to study the political, health system, legal, juridical, and socio-cultural realities surrounding existing law and policy in their countries, and decide what kind of law they want (if any). The biggest challenge is to determine what is possible to achieve, build a critical mass of support, and work together with legal experts, parliamentarians, health professionals, and women themselves to change the law—so that everyone with an unwanted pregnancy who seeks an abortion can have it, as early as possible and as late as necessary.

Toward a definition of decriminalization of abortion

In simple terms, the decriminalization of abortion means removing specific criminal sanctions against abortion from the law, and changing the law and related policies and regulations to achieve the following:

not punishing anyone for providing safe abortion,
not punishing anyone for having an abortion,
not involving the police in investigating or prosecuting safe abortion provision or practice,
not involving the courts in deciding whether to allow an abortion, and
treating abortion like every other form of health care—that is, using best practice in service delivery, the training of providers, and the development and application of evidence-based guidelines, and applying existing law to deal with any dangerous or negligent practices.

Some history

Abortion was legally restricted in almost every country by the end of the nineteenth century. The most important sources of such laws were the imperial countries of Europe—Britain, France, Portugal, Spain, and Italy—who imposed their own laws forbidding abortion on their colonies.

According to the United Nations Population Division’s comprehensive website on abortion laws, legal systems under which abortion is legally restricted fall into three main categories, developed mostly during the period of colonialism from the sixteenth century onward:

common law: the UK and most of its former colonies—Australia, Bangladesh, Canada, India, Ireland, Malaysia, New Zealand, Pakistan, Singapore, the United States, and the Anglophone countries of Africa, the Caribbean, and Oceania;
civil law: most of the rest of Europe, including Belgium, France, Portugal, Spain, and their former colonies, Turkey and Japan, most of Latin America, non-Anglophone sub-Saharan Africa, and the former Soviet republics of Central and Western Asia. In addition, the laws of several North African and Middle Eastern countries have been influenced by French civil law; and
Islamic law: the countries of North Africa and Western Asia and others with predominantly Muslim populations, and having an influence on personal law, for example, Bangladesh, Indonesia, Malaysia, and Pakistan. 1

Historically, restrictions on abortion were introduced for three main reasons:

Abortion was dangerous and abortionists were killing a lot of women. Hence, the laws had a public health intention to protect women—who nevertheless sought abortions and risked their lives in doing so, as they still do today if they have no other choice.
Abortion was considered a sin or a form of transgression of morality, and the laws were intended to punish and act as a deterrent.
Abortion was restricted to protect fetal life in some or all circumstances.

Since abortion methods have become safe, laws against abortion make sense only for punitive and deterrent purposes, or to protect fetal life over that of women’s lives. While some prosecutions for unsafe abortions that cause injury or death still take place, far more often existing laws are being used against those having and providing safe abortions outside the law today. Ironically, it is restrictive abortion laws—leftovers from another age—that are responsible for the deaths and millions of injuries to women who cannot afford to pay for a safe illegal abortion.

This paper provides a panoramic view of current laws and policies on abortion in order to show that, from a global perspective, few of these laws makes any legal or public health sense. The fact is that the more restrictive the law, the more it is flouted, within and across borders. Whatever has led to the current impasse in law reform for women’s benefit—whether it is called stigma, misogyny, religion, morality, or political cowardice—few, if any, existing laws on abortion are fit for purpose.

Efforts to reform abortion law and practice since 1900

The first country to reform its abortion law was the Soviet Union, spurred by feminist Alexandra Kollantai, through a decree on women’s health care in October 1920. 2 Since then, progressive abortion law reform (the kind that benefits women) has been justified on public health and human rights grounds, to promote smaller families for population and environmental reasons, and because women’s education and improved socioeconomic status have created alternatives to childbearing. Perhaps most importantly, controlling fertility has become both technically feasible and acceptable in almost all cultures today. Yet despite 100 years of campaigning for safe abortion, the use of contraception has been completely decriminalized while abortion has not.

Abortion is one of the safest medical procedures if done following the World Health Organization’s (WHO) guidance. 3 But it is also the cause of at least one in six maternal deaths from complications when it is unsafe. 4 In 2004, research by WHO based on estimates and data from all countries showed that the broader the legal grounds for abortion, the fewer deaths there are from unsafe abortions. 5 In fact, the research found that there are only six main grounds for allowing abortion apply in most countries:

ground 1 – risk to life
ground 2 – rape or sexual abuse
ground 3 – serious fetal anomaly
ground 4 – risk to physical and sometimes mental health
ground 5 – social and economic reasons
ground 6 – on request

With each additional ground, moving from ground 1 to 6, the findings show that the number of deaths falls. Countries with almost no deaths from unsafe abortion are those that allow abortion on request without restriction.

This is proof that that the best way to consign unsafe abortion to history is by removing all legal restrictions and providing universal access to safe abortion. But the question remains, how do we get from where things are now to where they could (and should) be?

Attempts to move from almost total criminalization to partial (let alone total) decriminalization of abortion have been slow and fraught with difficulties. Why? Because the best way to control women’s lives is through (the risk of) pregnancy. The traditional belief that women should accept “all the children God gives,” the recent glorification of the fetus as having more value than the woman it is dependent on, and male-dominated culture are all used extremely effectively to justify criminal restrictions. Nevertheless, the need for abortion is one of the defining experiences of having a uterus.

Globally, 25% of pregnancies ended in induced abortion in 2010–2014, including in countries with high rates of contraceptive prevalence. 6 Increasingly, thanks to years of effective campaigning, more and more women are defending the need for abortion, as well as the right to a safe abortion—and access to it if and when they need it. Moreover, a growing number of governments, in both the Global North and more recently the Global South, have begun to acknowledge that preventing unsafe abortions is part of their commitment to reducing avoidable maternal deaths and their obligations under international human rights law.

While some people still wish that this could be achieved through a higher prevalence of contraceptive use or post-abortion care alone, the facts are against it. Those facts include both the occurrence of contraceptive failure among those who do use a method and the failure to use contraception, both of which are common events and sexual behaviors.

The role of international human rights bodies in calling for law reform

A new layer of involvement in advocacy for safe abortion, based on an analysis of how existing laws affect women and girls and whether they meet international human rights standards, has emerged in recent years. United Nations human rights bodies—including the Human Rights Committee, the Committee on the Elimination of Discrimination against Women, the Committee on Economic, Social and Political Rights, the Working Group on discrimination against women in law and practice, and the Special Rapporteurs on the right to the highest attainable standard of health, the rights of women in Africa, and torture—have played an increasingly visible role in calling for progressive abortion law reform. 7

Regional bodies such as the Inter-American Court of Human Rights, the European Court of Human Rights, and the African Commission on Human and Peoples’ Rights (ACHPR) have been very active in this regard as well. The ACHPR called in January 2016 for the decriminalization of abortion across Africa, in line with the Maputo Protocol, and renewed that call in January 2017, making waves across the region. 8

Legalize or decriminalize: What’s in a word?

Interestingly, no human rights body has gone so far as to call for abortion to be permitted at the request of the woman, yet many have called for abortion to be decriminalized. This raises the question of what is understood in different quarters by the term “decriminalization.”

For many years, the abortion rights movement internationally has called for “safe, legal abortion.” More recently, calls for the “decriminalization of abortion” have also emerged. Do these mean the same thing? In simplistic terms, they might be differentiated like this: legalizing abortion means keeping abortion in the law in some form by identifying the grounds on which it is allowed, while decriminalizing abortion means removing criminal sanctions against abortion altogether.

In that sense, abortion is legal on one or more grounds (mostly as exceptions to the law) in all but a few countries today, while Canada stands out as the only country to date that, through a Supreme Court decision in 1988, effectively decriminalized abortion altogether. 9 No other country, no matter how liberal its law reform, has been willing to take abortion completely out of the law that delimits it.

However, this distinction is often not what is meant. Instead, the two terms are used interchangeably—that is, abortion may be legalized or decriminalized on some or all grounds. No one is likely to be able to change this lack of differentiation in terminology. Nevertheless, it is crucial when recommending abortion law reform to be clear what exactly is and is not intended. I will come back to this later in the paper, after exploring the complexity of the changes being called for, no matter which of the two terms is used.

The law on abortion in countries today

Criminal restrictions on the practice of abortion are contained in statute law—in other words, laws passed by legislatures, sometimes as part of criminal or penal codes, which consolidate a group of criminal statutes. In the UK, for example, abortion was criminalized in sections 58 and 59 of the Offences against the Person Act of 1861, with one aspect further defined in the Infant Life Preservation Act of 1929, and then allowed on certain grounds and conditions in Great Britain (but not Northern Ireland) in the 1967 Abortion Act, which was then amended further in the Human Fertilisation and Embryology Act of 1990. In the 1967 Abortion Act, legal grounds for abortion are set out as exceptions to the criminal law, yet the 1861 act is still in force and still being used to prosecute illegal abortions today. 10

Ireland, formerly a part of the UK, was also subject to the 1861 Offences against the Person Act and revoked sections 58–59 only in the Protection of Life during Pregnancy Act of 2013, which imposed its own almost total criminalization of abortion. 11 Sierra Leone, a former British colony, also revoked the 1861 Offences against the Person Act in the Safe Abortion Act, passed in December 2015 and again a second time unanimously in February 2016. That act allows abortion on request during the first 12 weeks of pregnancy, and until week 24 in cases of rape, incest, or risk to health of the fetus or the woman or girl, but it was not finally signed into law. 12

At the end of the twentieth century, abortion was legally permitted to save the life of the woman in 98% of the world’s countries. 13 The proportion of countries allowing abortion on other grounds was as follows: to preserve the woman’s physical health (63%); to preserve the woman’s mental health (62%); in case of rape, sexual abuse, or incest (43%); fetal anomaly or impairment (39%); economic or social reasons (33%); and on request (27%).

The number of countries in 2002 that permitted each of these grounds varied greatly by region. Thus, abortion was permitted upon request in 65% of developed countries but only 14% of developing countries, and for economic and social reasons in 75% of developed countries but only 19% of developing countries. 14 Some countries permit additional grounds for abortion, such as if the woman has HIV, is under the age of 16 or over the age of 40, is not married, or has many children. A few also allow it to protect existing children or because of contraceptive failure. 15

These percentages, published in 2002, are out of date, but they have not changed dramatically. In late 2017, research updating the world’s laws on abortion and adding new information about related policies, conducted under the aegis of the Department of Reproductive Health and Research/Human Reproductive Programme at WHO, will be incorporated into the United Nations Population Division’s website. 16

Regulating abortion

There is much more to this story, however. In addition to statute law, other ways to liberalize, restrict, or regulate access to abortion, which also have legal standing, include the following:

national constitutions in at least 20 countries, such as the Eighth Amendment to the Constitution (1983) in Ireland;
supreme court decisions, such as in the United States (1973, 2016), Canada (1988), Colombia (2006), and Brazil (2012), as well as higher court decisions, such as in India (2016, 2017) allowing individual women abortions beyond the 20-week upper limit;
customary or religious law, such as interpretations of Muslim law that allow abortion up to 120 days in Tunisia and the United Arab Emirates but do not allow abortion at all in other majority Muslim countries;
regulations that require confidentiality on the part of health professionals on the one hand, but on the other hand require health professionals to report a criminal act they may learn of, for example, while providing treatment for complications of unsafe abortion;
medical ethical codes, which, for example, allow or disallow conscientious objection; and
clinical and other regulatory standards and guidelines governing the provision of abortion, such as reporting guidelines, disciplinary procedures, parental or spousal consent, and restrictions on which health professionals may provide abortions and where, who may approve an abortion, and which methods may be used—as adjuncts to (though not always formally part of) the law.

Reed Boland has found that the distinction between laws and regulations governing abortion is not always clear and that some countries, usually those where abortion laws are highly restrictive, have issued no regulations at all. In the most complex cases, there are multiple texts over many years which may contain conflicting provisions and obscure and outdated language. The upshot may be that no one is sure when abortion is actually allowed and when it isn’t, which may serve to stop it being provided safely and openly at all. 17

Uganda is a case in point. According to a recently published paper by Amanda Cleeve et al., Uganda’s Constitution and Penal Code conflict with each other, leading to ambiguous interpretations and lack of awareness of the fact that abortion is legal to protect women’s health and life. Moreover, while Uganda has a national reproductive health policy, it is not supported in law and is not being implemented. In 2015, in order to clarify this situation, the minister of health and other stakeholders developed Standards and Evidence-based Guidelines on the Prevention of Unsafe Abortion . These included details of who can provide abortions, and where and how, and assigned health service responsibilities, such as level of care and post-abortion care. However, the guidelines were withdrawn in January 2016 due to religious and political opposition. 18

Post-abortion care to treat the consequences of unsafe abortions has been instituted since it was approved in the International Conference on Population and Development’s Programme of Action in 1994, in countries where there was little or no prospect of law reform, as a stopgap measure, to save lives. But this has not been a success in African countries such as Tanzania, where, under the 1981 Revised Penal Code, it remains unclear whether abortion is legal to preserve a woman’s physical or mental health or her life, and where 16% of maternal deaths are still due to unsafe abortions. 19 Although the government has tried to expand the availability of post-abortion care, a 2015 study found that “significant gaps still existed and most women were not receiving the care they needed.” 20 In early 2016, according to a CCTV-Africa report, the newly appointed prime minister, in tandem with the president, threatened to dismiss and possibly imprison doctors performing illegal abortions following recent reports of doctors in both public and private hospitals accepting payments for doing abortions and a reported increase in cases of complications. 21

Sometimes, other laws unrelated to abortion create barriers. In Morocco, the abortion law was established in 1920 when Morocco was a French protectorate. In May 2015, following a public debate arising from reports of women’s deaths from unsafe abortion, a reform process to expand legal protections was initiated by a directive of the king. According to the Moroccan Family Planning Association, despite a consensus that abortion should be permitted within the first three months if the woman’s physical and mental health is in danger, and in cases of rape, incest, or congenital malformation, unmarried women would be excluded because it is illegal to have sex outside marriage. 22

In India, a very liberal abortion law for its day was passed in 1971, but it has been poorly and unevenly implemented, such that high rates of morbidity and mortality persist to this day. 23 Even 15 years ago, the process for clinic registration as an approved abortion provider was arduous, limiting the number of clinics. 24 Moreover, two other laws have led to restrictions on abortion access: the Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act, which forbids ultrasound for purposes of sex determination and has led to restrictions on all second-trimester abortion provision, and the Protection of Children from Sexual Offences Act, which requires reporting of underage sex, so that minors who become pregnant cannot feel safe if they seek an abortion. 25

Restricting abortion without changing the law

Decent laws and policies can be sabotaged and access to abortion can be restricted without amending the law itself, but instead through policies pressuring women to have more children, public denunciation of abortion by political and religious leaders, or restricting access to services. Bureaucratic obstacles may be placed in women’s paths, such as requiring unnecessary medical tests, counselling even if women feel no need for it, having to get one or more doctors’ signatures, having to wait between making an appointment and having an abortion, or having to obtain consent from a partner, parent(s) or guardian, or even a judge.

In Turkey, for example, in 1983, in response to population growth, the government passed a law allowing fertility regulation, termination of pregnancy on request up to 10 weeks after conception, and sterilization. A married woman seeking an abortion was required only to obtain her husband’s permission or submit a formal statement of assumption of all responsibility prior to the procedure. 26 In recent years, however, President Erdogan has taken a pronatalist stance and urged Turkish couples to have at least three children. Since 2012, he has been calling abortion murder, expressing opposition to the provision of abortion services and threatening to restrict the law. Women protested against these threats in such large numbers in 2012 that to date there have been no changes to the law itself. But administrative changes were made in order to make the procedure for booking an appointment for an abortion—which is still primarily provided by gynecologists in hospitals—more difficult.

These changes have made it nearly impossible to obtain an abortion in a state hospital; indeed, some state hospitals have stopped providing abortions altogether. Although comparative data are not available, a 2016 study found that of 431 state hospitals with departments of obstetrics and gynecology, only 7.8% provided abortions without restriction as to reason, 78% provided abortions only if there was a medical necessity, and 11.8% did not provide abortions at all. Of the 58 teaching and research hospitals with departments of obstetrics and gynecology, only 17.3% provided abortion services without restriction as to reason, 71.1% only if there was a medical necessity, and 11.4% not at all. Overall, 53 of 81 provinces in Turkey did not have a state hospital that provided abortions without restriction as to reason, although this is permitted under the law. 27

Thus, the availability of safe abortion depends not only on permissive legislation but also on a permissive environment, political support, and the ability and willingness of health services and health professionals to make abortion available. In contrast to Turkey, Ethiopia is an example of the success of that support.

Law reform for the better—slowly but surely

In 2005, Ethiopia liberalized its abortion law. Previously, abortion was allowed only to save the life of the woman or protect her physical health. The current law allows abortion in cases of rape, incest, or fetal impairment, as well as if the life or physical health of the woman is in danger, if she has a physical or mental disability, or if she is a minor who is physically or mentally unprepared for childbirth. 28 This is a liberal law for sub-Saharan Africa, but for a long time, little was known about the extent of its implementation. In 2006, the government published national standards and guidelines on safe abortion that permitted the use of misoprostol, with or without mifepristone, in accordance with WHO guidance. A nationwide study in 2008 by the Guttmacher Institute estimated that within a few years, 27% of abortions were legal, though most abortions were still unsafe.

A 2011 study by Jemila Abdi and Mulugeta Gebremariam found that Ethiopian health care providers’ reasons for not providing abortions were mainly personal or due to lack of permission from an employer or the unavailability of services at their facility. Only 27% felt comfortable working at a site where abortion was provided. Reasons for not being comfortable were mainly religious, but also included personal values and a lack of training. Although 29% thought it should be a woman’s choice to have an abortion, 55% disagreed. The study also uncovered a lack of medical equipment and trained personnel, and bureaucratic problems at clinical sites. 29

Even so, major efforts were and are still being made to improve access at the primary level by constructing more health centers and training more mid-level providers. Between 2008 and 2014, the proportion of abortions provided in health facilities almost doubled. In 2014, almost three-fourths of facilities that could potentially provide abortions or post-abortion care did so, including 67% of the 2,600 public health centers nationwide, 80% of the 1,300 private or nongovernmental facilities, and 98% of the 120 public hospitals. The proportion of all abortion-related services provided by mid-level health workers increased from 48% in 2008 to 83% in 2014. While a substantial number of abortions continue to occur outside of health facilities, the proportion is falling, showing that change is possible but also that it takes time. 30

In recent decades in Latin America, a combination of legal reforms, court rulings, and public health guidelines have improved access to safe abortion for women. 31 These include allowing abortion on request in the first trimester of pregnancy, as in Mexico City (since 2007), and in Uruguay (since 2012). In Argentina, Bolivia, Brazil, Colombia, and Costa Rica, higher courts have been instrumental in interpreting the constitutionality and scope of specific grounds for abortion, though their judgments are not always implemented. In countries such as Peru, guidelines issued by hospitals or by governments at federal or state levels govern the enforcement of permitted grounds. 32 Additional steps needed constitute a huge task, as Ethiopia has shown—training providers and ensuring that services provide legal abortions, as well as informing women that these changes are taking place and that services are available.

Self-use of medical abortion in the absence of law and policy reform

In other Latin American countries, abortion laws have remained highly restrictive in spite of campaigns for women’s sexual and reproductive rights and human rights for more than 30 years. As a result, and thanks to the advent of new technology, women have begun to take matters into their own hands. An uncounted number of women, probably in the millions, has been obtaining and using misoprostol to self-induce abortion (widely available for gastric ulcers) from a range of sources—pharmacies, websites, black market—since its abortifacient effectiveness was first discovered in the late 1980s. This practice, begun in Brazil, has spread to many other countries and regions. In response, legal restrictions and regulations on access to medical abortion pills have been imposed by countries such as Brazil and Egypt in an effort to stop the unstoppable.

Moreover, in the past decade, feminist groups have set up safe abortion information hotlines in at least 20 countries, and health professionals are providing information and access to abortion pills via telemedicine, including Women Help Women, Women on Web, safe2choose, the Tabbot Foundation in Australia, and TelAbortion in the United States. 33

In Uruguay, which has hospital-based outpatient abortion care, Lilian Abracinskas, executive director of Mujer y Salud en Uruguay, said in a recent interview, “ In Uruguay, we don’t have doctors who do abortions. Abortion with pills is the only way and it isn’t possible to choose another method, such as manual vacuum aspiration. Health professionals are willing to be involved before and after, but not in the abortion.” 34 Thus, abortion service delivery has been reduced to providing information, prescribing pills, and conducting a follow-up appointment if the woman has concerns. It can be that simple (although it does restrict access to aspiration and surgical methods).

Abortion law as a political football and a weapon against women

While the overall trend globally is toward more progressive laws, some countries where the rightwing has taken power have gone backward. In Chile, from 1931 to 1989, the law allowed abortion on therapeutic grounds, described in the Penal Code as “termination of a pregnancy before the fetus becomes viable for the purpose of saving the mother’s life or safeguarding her health.” Pinochet, the dictator who overthrew the Allende government, banned abortion in 1989 as he left office, leaving no legal grounds at all. 35 It took until 2016 for Michelle Bachelet’s government, during her second term in office, to introduce a bill permitting three grounds for legal abortion—to save the woman’s life, in cases of rape or sexual abuse, and in cases of fatal fetal anomaly—which are more narrow than what was in place between 1931 and 1989 but are the best that its supporters think they can achieve today. 36

In Russia, the law has gone back and forth between permissive and restrictive with every change of political head of state. Stalin made abortion illegal when he took over from Lenin, and then after 1945, abortion was again permitted on broad grounds across the Soviet Union and in its satellite countries in Eastern Europe and West Asia, while under Vladimir Putin a long list of restrictions has been imposed, greatly reducing the number of grounds on which abortion is permitted. In January 2016, a bill aiming to “rule out the uncontrolled use of pharmaceutical drugs destined for termination of pregnancy” was tabled in parliament. It would have banned retail sales and limited the list of organizations permitted to buy medical abortion pills wholesale. It would also have banned abortions in private clinics and removed payment for them from state insurance policies. And it would not have allowed abortions to be covered by state health care unless the pregnancy threatened the woman’s life. The bill was withdrawn after strong public protest that was coordinated by the Russian Association for Population and Development; however, attempts at further restriction are likely to continue. 37

In a number of Central and Eastern European countries, the backlash against communist rule and the increasing influence of conservative religious figures has led to regular attempts to undermine permissive abortion laws. Poland has had the worst of it. In 1993, a liberal law was replaced by a very restrictive law that removed “difficult living conditions” as a legal ground for abortion, leaving only three grounds: serious threat to the life or health of the pregnant woman, as attested by two physicians; cases of rape or incest if confirmed by a prosecutor; and cases in which antenatal tests, confirmed by two physicians, demonstrated that the fetus was seriously and irreversibly damaged. 38 This law, in spite of an attempt to ban all abortions in 2016, remains in place due to months of national action by women’s groups, including a national women’s strike on October 3, 2016. However, in November 2016, the government approved a regulation offering pregnant women carrying a seriously disabled or unviable fetus a one-time payment of €1,000 to carry the pregnancy to term, even if the baby would be born dead or die soon after delivery. The package includes access to hospice and medical care, psychological counselling, baptism or a blessing and burial, and a person who will act as an “assistant to the family” and coordinate the support. The purported aim was to reduce the number of legal abortions on grounds of fetal anomaly. 39 This horrendous proposal, nasty anti-abortion propaganda, and systematic pressure on hospitals in Poland to stop doing abortions on medical grounds exemplify the right-wing extremism of the anti-abortion movement today, whose epicenter is in the United States and whose war on women sometimes feels relentless. 40

But this is not stopping women from having abortions.

Keeping laws and policies that benefit women in clear sight

Cuba was the first country in Latin America and the Caribbean to reform its abortion law in favor of women, with a law that remains unique. Since 1965, abortion has been available on request up to the tenth week of pregnancy through the national health system. The Penal Code, adopted in 1979, says that an abortion is considered illegal only if it is without the consent of the pregnant woman, is unsafe, or is provided for profit. 41

In Japan, the law allowing abortion, enacted in 1948, was initially based on eugenics but was a liberal law in practice. Under this law, abortion became the primary mode of birth control in the country. The law was reformed in 1996 to omit all references to eugenics. Abortion is now permitted to protect health, which includes socioeconomic reasons, and in cases of sexual offenses. Abortion was and remains the main form of fertility control. The great majority of abortions fall under the health protection indication. Nearly all abortions are in the first trimester. 42

In recent years in some countries, laws to legalize abortion are found in public health statutes, court decisions, and policies and regulations on sexual and reproductive health care, rather than as part of the criminal law. Uruguay’s 2012 law is an example of public health legislation that sets out procedures and health care standards for the provision of abortion services. 43

In December 2014, the parliament of Luxembourg voted to remove abortion from the Penal Code up to 12 weeks of pregnancy and said that the woman no longer had to show she was “in distress” due to her pregnancy. Regulations on who can provide abortions were also revised. 44 In France, in 2014, 2015, and 2016, the 1975 Veil Law was reformed to increase access to abortion and reduce barriers. Women no longer have to be in a “state of distress” in France either, but need only request an abortion. The required seven-day “reflection period” between the request for an abortion and the abortion itself was also dropped. Most recently, midwives are now permitted to provide medical abortion, and the costs for all abortions are now reimbursed. 45

Sweden’s law is among the most liberal, though abortion is not entirely decriminalized. The Swedish law was amended in 1938, 1946, 1963, 1975, 1995, 2007, and 2008. Abortion is available on request up to 18 weeks. After that, permission from the National Board of Health and Welfare is required and may not be granted if the fetus is viable. Appeal is not permitted. Regulations govern who provides abortions and where. Any person not authorized to practice medicine who performs an abortion on another person can be fined or imprisoned for up to a year. Abortion is subsidized by the government; 95% of abortions take place before 12 weeks, and almost none after 18 weeks. Most are medical abortions. 46

In Australia, each state and the Capital Territory have a different law, ranging from very liberal to very restrictive; several are in the process of change. 47 In the United States in 1973, the Supreme Court held that criminalizing abortion violated a woman’s right to privacy and said that abortion should be a decision between a woman and her doctor. However, the court also held that US states have an interest in ensuring the safety and well-being of pregnant women, as well as the potential of human life. This opened a door to restrictions that become greater as pregnancy progresses, opening a Pandora’s box for states to impose restrictions that are tying up state and federal courts to this day:

first trimester: a state cannot regulate abortion beyond requiring that the procedure be performed by a licensed doctor in medically safe conditions;
second trimester: a state may regulate abortion if the regulations are reasonably related to the health of the pregnant woman; and
third trimester: the state’s interest in protecting the potential human life outweighs the woman’s right to privacy, and the state may prohibit abortions unless abortion is necessary to save her life or health. 48

It is impossible not to think that no law is the best law when it comes to abortion, which brings us back to Canada, where abortion has not been restricted since 1988 and is available on request with no stipulations as to who must provide it or where. 49 Although abortion is not easily accessible in remote areas, and Canada was exceedingly slow to approve mifepristone, 50 opposition to abortion has never developed a foothold. The benefits for women of having no law are crystal clear. 51

Legalization or decriminalization: Closing the circle

Although recent calls for the decriminalization of abortion by human rights bodies, politicians, and some feminist groups aim to decriminalize only certain grounds and conditions related to abortion, these are far better than nothing. Thus, in Chile, El Salvador, Honduras, and Peru, where abortion is severely legally restricted, calls to “decriminalize abortion” include only three to four grounds—to protect the life and health of the woman, in cases of severe or fatal fetal anomalies, and as a result of rape or sexual abuse. While the great majority of abortions are not for these reasons, they are the only grounds that stand a chance of achieving majority approval through law reform in settings where “everything” is simply not in the cards.

In Africa, the Maputo Protocol is legally binding on the 49 states that have ratified it. The 2016 call by the ACHPR for the decriminalization of abortion across Africa is based on the Maputo Protocol, which calls for safe abortion to be authorized by states “in cases of sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the fetus.” 52 However, in January 2017, at the African Leaders’ Summit on Safe and Legal Abortion, the ACHPR went further, calling for safe, legal abortion as a human right, which by any definition surely exceeds the Maputo Protocol’s boundaries. 53

At bottom, the extent of decriminalization aimed for is a choice between the ideal and the practicable, and reflects the extent to which abortion is seen as a bona fide form of health care—not just by advocates for the right to safe abortion but also by politicians, health professionals, the media, and the public. The fact that abortion is still legally restricted in almost all countries is not just a historical legacy but indicative of the continuing ambivalence and negativity about abortion in most societies, no matter how old or where the law originally came from.

Some abortion rights supporters seem to have an underlying fear that without leaving something in the criminal law, “bad things” may start to happen. Canada proves this is not the case. Granted, not everywhere is Canada. But there are general criminal laws that allow the punishment of wrongdoing—such as forcing a woman to have an abortion against her will, giving her medical abortion pills without her knowledge, or causing injury or death through a dangerous procedure. These are laws against grievous bodily harm, assault, or manslaughter, which can be applied without the need for a criminal statute on abortion.

Changing the law to benefit women

Successfully changing the law on abortion is the work of years. Advocates do not get a lot of chances to change the law and need to decide what they want to end up with before campaigning for it, with the confidence that whatever they propose has a chance of being implemented. Another chance may not come again soon.

Allies are crucial. Most important are parliamentarians, health professionals, legal experts, women’s groups and organizations, human rights groups, family planning supporters—and above all, women themselves. Achieving a critical mass of support among all these groups is key to successful law reform, as is defeating the opposition, which can have an influence beyond its numbers.

Those unable to contemplate no law at all must confront the fact that each legal ground for abortion may be interpreted liberally or narrowly, and thereby implemented differently in different settings, or may not be implemented at all. The challenge is to define which abortions should remain criminal and what the punishment should be. Even if only some grounds would be considered acceptable, the question of who decides and on what basis remains when reforming existing law.

Wording becomes critical to supporting good practice. For example, grounds which are based on risk are particularly tricky. The definition of “risk” is itself complex, and the extent of risk may be hedged with uncertainty. Risk to the woman’s life, health, or mental health and risk of serious fetal anomaly have been subjected to challenge and disagreement among professionals. As Christian Fiala, head of the Gynmed Ambulatorium in Austria, has noted, “There is only one way to be sure a woman’s life is at risk, that is—after she dies.” 54

Reed Boland explores the importance of wording in depth with regard to the health ground for abortion:

The wording of [the health] indication varies greatly from country to country, particularly given the range of languages and legal traditions involved. Sometimes … there must be a risk to health. Great Britain’s law, for example … allows abortion where “continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman …” Sometimes … there must be a danger to health. Burkina Faso’s Penal Code permits abortions when “continuation of the pregnancy … endangers the health of the woman …” And in some countries there must only be medical or health reasons. In Vanuatu, there must be “good medical reasons”, in Djibouti “therapeutic reasons”, and in Pakistan a requirement of “necessary treatment”. These concepts are not necessarily the same. 55

Legislating on second-trimester abortions presents particular difficulties. Many laws say little or nothing about second-trimester abortions, which has a proscriptive effect. Second-trimester abortions constitute an estimated 10–15% of abortions globally, but as many as 25% in India and South Africa due to poor access to services. When they are unsafe, they account for a large proportion of hospital admissions for treatment of complications and are responsible for a disproportionate number of deaths. Hence, the law should protect second-trimester abortions assiduously. Yet social disapproval of these abortions can run high, and laws tend to be increasingly restrictive as pregnancy progresses, even laws that are liberal with regard to the first trimester. The mistaken belief that second-trimester abortions can be legislated away persists, despite the facts. 56

Restrictive abortion laws are being broken on a daily basis by millions of women and numerous abortion providers. Even in countries where the law is less restrictive, research shows that the letter of the law is being stretched in all sorts of ways to accommodate women’s needs. Yet opposition and a stubborn unwillingness to act continue to hamper efforts to meet women’s need for abortion without restrictions.

Conclusions

It should be clear that the plethora of convoluted laws and restrictions on abortion do not make any legal or public health sense. What makes abortion safe is simple and irrefutable—when it is available on the woman’s request and universally affordable and accessible. From this perspective, few existing laws are fit for purpose but merely repeat every possible permutation of the self-same restrictions.

The aim of this paper was not to provide answers or roadmaps, because in every country prevailing conditions must be taken into account. The aim was to motivate transformative thinking about whether any criminal law on abortion is necessary. Treating abortion as essential health care is a major step forward, and where the national setting insists on some sort of law, advocates could draft the simplest, most supportive law possible, placing first-trimester abortion care at the primary and community level, ensuring second-trimester services, involving mid-level providers, increasing women’s awareness of services and the law, aiming for universal access, integrating WHO-approved methods, and addressing social attitudes to reduce opposition. Space did not permit me to raise the issues of cost and public versus private services, but they are two major aspects that deserve priority consideration.

If it were up to me, all criminal sanctions against abortion would be revoked, making abortion available at the request of the only person who counts—the one who is pregnant. And as with all pregnancy care, abortion would be free at the point of care and universally accessible from very early on in pregnancy.

Canada has proved that no criminal law is feasible and acceptable. Sweden has proved that abortions after 18 weeks can effectively disappear with very good services, and WHO has shown that first-trimester abortions can be provided safely and effectively at the primary and community level by trained mid-level providers and provision of medical abortion pills by trained pharmacy workers. Finally, web- and phone-based telemedicine services are showing that clinic-based services are not required to provide medical abortion pills safely and effectively.

But to achieve these goals, or something close to them, it takes a strong and active national coalition, a critical mass of support, and—with luck and knowing what the goalposts are—less than 100 years of campaigning to make change happen on the ground.

Acknowledgments

This paper began as a presentation on the decriminalization of abortion at the FIAPAC Conference in Lisbon on October 13, 2016. I would like to thank the following individuals for information presented there that enriched this paper: Angela Dawson (information on Australia), Hamida Nkata (information on Tanzania), S. Sinan Ozalp (information on Turkey), Emily McLean (information on Ethiopia), Amanda Cleeve (information on Uganda), Joyce Arthur (information on Canada), and Amanda Huber (information on Laos). Much of the recent country-based information here was gleaned during my editing of the International Campaign for Women’s Right to Safe Abortion newsletter. 57 Many thanks to Sally Sheldon and Kinga Jelinska for helpful comments on a previous draft. Any errors are my own.

Legalized Abortion and the Public Health: Report of a Study (1975)

Chapter: summary and conclusions.

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

SUMMARY AND CONCLUSIONS The legal status of abortion in the United States became a heightened national issue with the January 1973 rulings by the Supreme Court that severely limited states' rights to control the procedure. The Court's decisions on the historic cases of Roe v. Wade and Doe v. Bolton precluded any state interference with the doctor-patient decision on abortion during the first trimester (three months) of pregnancy. During the second trimester, a state could intervene only to the extent of insisting on safe medical practices "reasonably related to maternal health." And for approximately the final trimester of a pregnancyâwhat the Court called "the state subsequent to viability" of a fetusâa state could forbid abortion unless medical judgment found it necessary "for the preservation of the life or health of the mother." The rulings crystallized opposition to abortion, led to the intro- duction of national and state legislation to curtail or prohibit it, and generated political pressures for a national debate on the issue. Against this background of concerns about abortion, the Institute of Medicine in 1974 called together a committee to review the existing evidence on the relationship between legalized abortion and the health of the public. The study group was asked to examine the medical risks to women who obtained legal abortions, and to document changes in the risks as legal abortion became more available. Although there have been other publications on particular relationships between abortion and health, the Institute's study is an attempt to enlist scholars, researchers, health practitioners, and concerned lay persons in a more comprehensive analysis of the available medical information on the subject. Ethical issues of abortion are not discussed in this analysis, nor are questions concerning the fetus in abortion. The study group recog- nizes that this approach implies an ethical position with which some may disagree. The emphasis of the study is on the health effects of abortion, not on the alternatives to abortion.

Abortion legislation and practices are important factors in the relationship between abortion and health status. In order to examine legislation and court decisions that have affected the availability of legal abortion in the U.S., the study group classified the laws and practices into three categories: restrictive conditions, under which abortion is prohibited or permitted only to save the pregnant woman's life; moderately restrictive conditions, under which abortion is per- mitted with approval by several physicians, in a wider range of circumstances to preserve the woman's physical or mental health, prevent the birth of a child with severe genetic or congenital defects, or terminate a pregnancy caused by rape or incest; and non-restrictive conditions, under which abortion essentially is available according to the terms of the Supreme Court ruling. Before 1967, all abortion laws in the United States could be classified as restrictive. Easing of restrictions began in 1967 with Colorado, and soon thereafter 12 other states also adopted moderately restrictive legislation to expand the conditions under which therapeutic abortion could be obtained. In 1970, four states (Alaska, Hawaii, New York, and Washington) removed nearly all legal controls on abortion. Non-restrictive conditions have theoretically existed throughout all fifty states since January 22, 1973, the date of the Supreme Court decision. There is evidence that substantial numbers of illegal abortions were obtained in the U.S. when restrictive laws were in force. Although some of the illegal abortions were performed covertly by physicians in medical settings, many were conducted in unsanitary surroundings by unskilled operators or were self-induced. In this report, "illegal abortion" generally refers to those performed by a non-physician or the woman herself. The medical risks associated with the last two types of illegal abortions are patently greater than with the first. A recent analysis of data from the first year of New York's non- restrictive abortion legislation indicates that approximately 70 percent of the abortions obtained legally in New York City would otherwise have been obtained illegally. Replacement of legal for illegal abortions also is reflected in the substantial decline in the number of reported complications and deaths due to other-than-legal abortions since non- restrictive practices began to be implemented in the United States. The number of all known abortion-related deaths declined from 128 in 1970 to 47 in 1973; those deaths specifically attributed to other-than-legal abortions (i.e., both illegal and spontaneous) dropped from 111 to 25 during the same period, with much of that decline attributed to a reduced incidence of illegal abortions. Increased use of effective con- traception may also have played a role in the decline of abortion-related deaths. Methods most frequently used in the United States to induce abortion during the first trimester of pregnancy are suction (vacuum aspiration) or dilatation and curettage (D&C). Abortions in the second trimester are usually performed by replacing part of the amniotic fluid that surrounds

the fetus with a concentrated salt solution (saline abortion), which usually induces labor 24 to 48 hours later. Other second trimester methods are hysterotomy, a surgical entry into the uterus; hysterectomy, which is the removal of the uterus; and, recently, the injection into the uterine cavity of a prostaglandin, a substance that causes muscular contractions that expel the fetus. Statistics on legal abortion are collected for the U.S. government by the Center for Disease Control. CDC's most recent nationwide data are for 1973, the year of the Supreme Court decision. Some of those figures are: â The 615,800 legal abortions reported in 1973 were an increase of approximately 29,000 over the number reported in 1972. These probably are underestimates of the actual number of abortions performed because some states have not yet developed adequate abortion reporting systems. â The abortion ratio (number of abortions per 1,000 live births) increased from 180 in 1972 to 195 in 1973. â More than four out of five abortions were performed in the first trimester, most often by suction or D&C. â Approximately 25 percent of the reported 1973 abortions were obtained outside the woman's home state. In 1972, before the Supreme Court decision, 44 percent of the reported abortions had been obtained outside the home state of the patient, primarily in New York and the District of Columbia. â Approximately one-third of the women obtaining abortions were less than 20 years old, another third were between 20 and 25, and the remaining third over 25 years of age. â In all states where data were available, about 25 percent of the women obtaining abortions were married. â White women obtained 68 percent of all reported abortions, but non-white women had abortion ratios about one-third greater than white women. In 1972, non-white women had abortion rates (abortions per 1,000 women of reproductive age) about twice those of whites in three states from which data were available to analyze. A national survey of hospitals, clinics, and physicians conducted in 1974 by The Alan Guttmacher Institute furnished data on the number of abortions performed in the U.S. during 1973, itemized by state and type of provider. A total of 745,400 abortions were reported in the survey, a figure higher than the 615,800 abortions reported in 1973 to CDC. The Guttmacher Institute obtains its data from providers of health services, while CDC gets most of its data from state health departments.

Risks of medical complications associated with legal abortions are difficult to evaluate because of problems of definition and subjective physician judgment. Available information from 66 centers is provided by the Joint Program for the Study of Abortion, undertaken by The Population Council in 1970-1971. The JPSA study surveyed almost 73,000 legal abortions. It used a restricted definition of major complications, which included unintended major surgery, one or more blood transfusions, three or more days of fever, and several other categories involving prolonged illness or permanent impairment. Although this study also collected data on minor complica- tions, such as one day of fever post-operatively, the data on major com- plications are probably more significant. The major complication rates published by the JPSA study and summarized below relate to women who had abortions in local facilities and from whom follow-up information was obtained. â Complications in women not obtaining concurrent sterilization and with no pre-existing medical problems (e.g., diabetes, heart disease, or gynecological problems) occurred 0.6 times per 100 abortions in the first trimester and 2.1 per 100 in the second trimester. â Complications in women not obtaining concurrent sterilization, but having pre-existing problems, occurred 2.0 times per 100 in the first trimester and 6.7 in the second. â Complications in women obtaining concurrent sterilization and not having pre-existing problems occurred 7.2 times per 100 in the first trimester and 8.0 in the second. â Women with both concurrent sterilization and pre-existing problems experienced complications approximately 17 times per 100 abortions regardless of trimester. The relatively high complication rates associated with sterilization in the JPSA study would probably be lower today because new sterilization techniques require minimal surgery and carry lower rates of complications. The frequency of medical complications due to illegal abortions cannot be calculated precisely, but the trend in these complications can be estimated from the number of hospital admissions due to septic and incomplete abortionâtwo adverse consequences of the illegal procedure.

The number of such admissions in New York City's municipal hospitals declined from 6,524 in 1969 to 3,253 in 1973; most restrictions on legal abortion in New York City were lifted in July of 1970. In Los Angeles, the number of reported hospital admissions for septic abortions declined from 559 in 1969 to 119 in 1971. Other factors, such as an increased use of effective contraception and a decreasing rate of unwanted pregnancies may have contributed to these declines, but it is probable that the introduction of less restrictive abortion legislation was a major factor. There has not been enough experience with legal abortion in the U.S. for conclusions to be drawn about long-term complications, particularly for women obtaining repeated legal abortions. Some studies from abroad suggest that long-term complications may include prematurity, miscarriage, or ectopic pregnancies in future pregnancies, or infertility. But research findings from countries having long experience with legal abortion are inconsistent among studies and the relevance of these data to the U.S. is not known; methods of abortion, medical services, and socio-economic characteristics vary from one country to another. Risks of maternal death associated with legal abortion are lowâ1.7 deaths per 100,000 first trimester procedures in 1972 and 1973âand less than the risks associated with illegal abortion, full-term pregnancy, and most surgical procedures. The 1973 mortality rate for a full-term pregnancy was 14 deaths per 100,000 live vaginal deliveries; the 1969 rate for cesarean sections was 111 deaths per 100,000 deliveries. For second trimester abortions, the combined 1972-73 mortality ratio was 12.2 deaths per 100,000 abortions. (For comparison, the surgical removal of the tonsils and adenoids had a mortality risk of five deaths per 100,000 operations in 1969). When the mortality risk of legal abortion is examined by length of gestation it becomes apparent that the mortality risks increase not only from the first to the second trimester, but also by each week of ges- tation. For example, during 1972-73, the mortality ratio for legal abortions performed at eight weeks or less was 0.5, and for those performed between nine and 10 weeks was 1.7 deaths per 100,000 legal abortions. At 11 to 12 weeks the mortality ratio increased to 4.2 deaths, and by 16 to 20 weeks, the ratio was more than 17 deaths per 100,000 abortions. Hysterotomy and hysterectomy, methods performed infrequently in both trimesters, had a combined mortality ratio of 61.3 deaths per 100,000 procedures. Some data on the mortality associated with illegal abortion are avail- lable from the National Center for Health Statistics (NCHS) and from CDC. In 1961 there were 320 abortion-related deaths reported in the U.S., most of them presumed by the medical profession to be from illegal abortion. By 1973, total reported deaths had declined to 47, of which 16 were specifi- cally attributed to illegal abortions. There has been a steady decline in the mortality rates (number of deaths per 100,000 women aged 15-44) associated with other-than-legal abortion for both white and non-white women, but in 1973 the mortality rate for non-white women (0.29) was almost ten times greater than that reported for white women (0.03).

Psychological effects of legal abortion are difficult to evaluate for reasons that include lack of information on pre-abortion psychological status, ambiguous terminology, and the absence of standardized measurements. The cumulative evidence in recent years indicates that although it may be a stressful experience, abortion is not associated with any detectable increase in the incidence of mental illness. The depression or guilt feelings reported by some women following abortion are generally described as mild and temporary. This experience, however, does not necessarily apply to women with a previous history of psychiatric illness; for them, abortion may be followed by continued or aggravated mental illness. The JPSA survey led to an estimate of the incidence of post-abortion psychosis ranging from 0.2 to 0.4 per 1,000 legal abortions. This is lower than the post-partum psychosis rate of one to two per 1,000 deliveries in the United States. Psychological factors also bear on whether a woman obtains a first or second-trimester abortion. Two studies in particular suggest that women who delay abortion into the later period may have more feelings of ambiva- lence, denial of the pregnancy, or objection on religious grounds, than those obtaining abortions in the first trimester. It is also apparent, however, that some second-trimester abortions result from procedural delays, difficulties in obtaining a pregnancy test, locating appropriate counseling, or arranging and financing the procedure. Diagnosis of severe defects of a fetus well before birth has greatly advanced in the past decade. Developments in the techniques of amniocen- tesis and cell culture have enabled a number of genetic defects and other congenital disorders to be detected in the second trimester of pregnancy. Prenatal diagnosis and the opportunity to terminate an affected pregnancy by a legal abortion may help many women who would have refrained from becoming pregnant or might have given birth to an abnormal child, to bear children unaffected by the disease they fear. Abortion, with or with- out prenatal diagnosis, also can be used in instances where there is reasonable risk that the fetus may be affected by birth defects from non-genetic causes, such as those caused by exposure of the woman to rubella virus infection or x-rays, or by her ingestion of drugs known to damage the fetus. Almost 60 inherited metabolic disorders, such as Tay-Sachs disease, potentially can be diagnosed before birth. More than 20 of these diseases already have been diagnosed with reasonaable accuracy by means of amniocentesis and other procedures. The techniques also can be used to identify a fetus with abnormal chromosomes, as in Down's syndrome (mongolism), and to discriminate between male and female fetuses, which in such diseases as hemophilia would allow determination of whether the fetus was at risk of being affected or simply at risk of being a hereditary carrier of the disorder.

In North America, amniocentesis was performed in more than 6,000 second-trimester pregnancies between 1967 and 1974. The diagnostic accuracy was close to 100 percent and complication rates were about two percent. Less than 10 percent of the diagnoses disclosed an affected fetus, meaning that the great majority of parents at risk averted an unnecessary abortion and were able to carry an unaffected child to term. There are many limitations to the use of prenatal diagnosis, especially for mass screening purposes. Amniocentesis is a fairly expensive procedure, and relatively few medical personnel are qualified to administer it and carry out the necessary diagnostic tests. Only a small number of genetic disorders can now be identified by means of amniocentesis and many couples still have no way to determine whether or not they are to be the parents of a child with genetic defects. Nevertheless, the avail- ability of a legal abortion expands the options available to a woman who faces a known risk of having an affected child. Abortion as a substitute for contraception is one possibility raised by the adoption of non-restrictive abortion laws. Limited data do not allow definitive conclusions, but they suggest that the introduction of non-restrictive abortion laws in the U.S. has not lead to any documented decline in demand for contraceptive services. Among women who sought abortion and who had previously not used contraception or had used it poorly, there is some evidence that they may have begun to practice contraception because contraceptives were made available to them at the time of their abortion. The health aspects of this issue bear on the higher mortality and mor- bidity associated with abortion as compared with contraceptive use, and on the possibility that if women rely on abortion rather than contraception they may have repeated abortions, for which the risk of long-term compli- cations is not known. The incidence of repeated legal abortions is little known because legal abortion has only been widely available in the U.S. for a few years. Data from New York City indicate that during the first two years of non-restrictive laws 2.45 percent of the abortions obtained by residents were repeat procedures. If those two years are divided into six-month periods, repeated legal abortions as a percent of the total rose from 0.01 percent in the first period to 6.02 percent in the last. Part of this increase is attributable to a statistical fact: the longer non-restrictive laws are in effect, the greater the number of women eligible to have repeated legal abortions. Perhaps, too, the reporting system has improved. In any case, some low incidence of repeated abortions is to be expected because none of the current contraceptive methods is completely failureproof, nor are they likely to be used with maximum care on all occasions.

8 A recent study has suggested that one additional factor contributing to the incidence of repeated abortions is that abortion facilities may not routinely provide contraceptive services at the time of the procedure. This is of concern because of recent evidence that ovulation usually oc- curs within five weeks and perhaps as early as 10 days after an abortion. The conclusions of the study group: â Many women will seek to terminate an unwanted pregnancy by abortion whether it is legal or not. Although the mortality and morbidity . associated with illegal abortion cannot be fully measured, they are clearly greater than the risks associated with legal abortion. Evidence suggests that legislation and practices that permit women to obtain abortions in proper medical surroundings will lead to fewer deaths and a lower rate of medical complications than restrictive legislation and practices. ââ¢ The substantial differences between the mortality and morbidity associated with legal abortion in the first and second trimesters suggest that laws, medical practices, and educational programs should enable and encourage women who have chosen abortion to obtain it in the first three months of pregnancy. â More research is needed on the consequences of abortion on health status. Of highest priority are investigations of long-term medical complications, particularly after multiple abortions the effects of abortion and denied abortion on the mental health and social welfare of individuals and families the factors of motivation, behavior, and access associated with contraceptive use and the choice of abortion.

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For Abortion Providers, a Tough Business Gets Even Tougher

After the fall of Roe v. Wade, some clinics thought they could expand their businesses in states that still allowed them to operate. It hasn’t quite worked out that way.

The interior of the entrance of Affirmative Care Solutions.

By Jennifer Miller

Providing abortion services has always been a difficult business, with tiny-to-nonexistent profit margins and often-challenging logistical obstacles. And the Supreme Court’s decision in Dobbs v. Jackson two years ago , which eliminated the constitutional right to an abortion, has made the landscape of reproductive services even tougher.

The fall of Roe v. Wade has pushed many abortion clinics to explore alternative markets for their services. Some clinics are moving to abortion-rights states or expanding their presence there, hoping to meet the needs of a more concentrated customer base. According to a recent analysis by The New York Times, out-of-state travel for abortions more than doubled in 2023 compared with travel in 2019, and made up nearly a fifth of recorded abortions.

Caitlin Myers, a professor of economics at Middlebury College who tracks clinic openings and closures nationwide , estimated that at least 12 new clinics opened directly in response to Dobbs and another six relocated after abortion was banned in their states.

Many clinics are finding out, however, that blue states can often be almost as hostile to their presence as red ones.

In September 2022, Dr. Matthew Reeves signed a lease for a new branch of the DuPont Clinic in Beverly Hills, Calif., as he sought to expand his reproductive health care clinic beyond its original location in Washington, D.C. In January of that year, as the future of Roe v. Wade looked increasingly uncertain, Dr. Reeves and Jennefer Russo, the chief medical officer of DuPont Clinic, had begun to think about opening an additional practice in a state that allowed access to abortions

“Dobbs was percolating and it became apparent that the Supreme Court was likely to overturn Roe v. Wade,” Dr. Russo said in an interview earlier this year. “Our thinking was that patients could come to L.A. if they lived west of the Mississippi.”

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Inside a medical practice sending abortion pills to states where they're banned

Elissa Nadworny

“Welcome to modern abortion care,” says Angel Foster, who leads operations at what’s known as the MAP, a Massachusetts telehealth provider sending pills to people who live in states that ban or restrict abortion. Elissa Nadworny/NPR hide caption

The packages, no bigger than a hardcover book, line the walls of the nondescript office near Boston. It's not an Etsy retailer or a Poshmark seller or, as the nearby post office workers believe, a thriving jewelry business.

These boxes contain abortion pills.

"Welcome to modern abortion care," says Angel Foster, as she holds up a box for mailing. Foster, who has an M.D. degree, leads operations at what's known as the MAP, a Massachusetts telehealth provider sending pills to people who live in states that ban or restrict abortion.

The MAP is one of just four organizations in the U.S. operating under recently enacted state shield laws, which circumvent traditional telemedicine laws requiring out-of-state health providers to be licensed in the states where patients are located. Eight states have enacted these shield laws.

Pregnant patients can fill out an online form, connect with a doctor via email or text and, if approved, receive the pills within a week, no matter which state they live in.

Dr. Stephanie Arnold, who is wearing a brightly colored jumpsuit, speaks with a patient who is sitting on an exam table with a medical drape over her lap.

Shots - Health News

Abortion is becoming more common in primary care clinics as doctors challenge stigma.

Shield law practices account for about 10% of abortions nationwide. There were 9,200 abortions a month provided under shield laws from January to March of this year, according to fresh data from the Society of Family Planning's WeCount project . And some researchers estimate that this number has risen since then and could be as high as 12,000 per month.

The rise of telehealth is part of why the number of abortions in the U.S. has continued to go up since the Supreme Court overturned Roe v. Wade in 2022 — even though 14 states have near-total abortion bans. In those states, shield law providers represent the only legal way people can access abortions within the established health care system.

In this photo, Angel Foster poses for a portrait. She's wearing a white T-shirt and is standing in front of a brick wall.

"If you want to have your abortion care in your state and you live in Texas or Mississippi or Missouri, right now shield law provision is by far the most dominant way that you'd be able to get that care," says Foster. Elissa Nadworny/NPR hide caption

Back in Massachusetts, Foster glances down at the list of today's patients. The practice's four OB-GYNs have signed off on prescriptions for nearly two dozen women — in Texas, Florida, Tennessee, Georgia, Alabama, Oklahoma and South Carolina. Most of today's patients are around six weeks along in their pregnancy. Many already have children.

"I really need an abortion pill. My state has banned it. My funds are really low," one patient wrote on the online form she filled out for the doctor.

"I'm a single mom with a kid under two," another wrote. "I can't afford a baby. I can't even afford this abortion."

Foster and her team serve patients who are up to 10 weeks pregnant and who are 16 or older. It costs $250 to get the two-drug regimen — mifepristone and misoprostol — in the mail, but there's a sliding scale and patients can pay as little as $5. The MAP is funded through abortion funds, individual donations and philanthropic gifts, and Foster has plans to apply for grants and state funding to help make the organization more sustainable. The MAP currently sends out about 500 prescriptions a month.

Yet to be tested in court, shield laws have some legal vulnerability

In the eight states with shield laws, abortion providers can treat out-of-state patients just as if they were in-state patients. The laws give abortion providers some protection from criminal prosecution, civil claims and extradition, among other threats. The laws have yet to be tested in court, but they certainly haven't gone unnoticed by lawmakers and groups looking to limit abortion.

"These websites are breaking the law … aiding and abetting crimes in Texas," says John Seago, the president of Texas Right to Life. "We want to use all the instruments that we have, all the tools available, to really fight against this new trend of abortion pills by mail."

Seago says providers should still be held responsible for committing a crime that is executed across state lines. "Mailing the abortion pill is a state jail felony according to our pro-life laws," he says, "but enforcement of those policies has been a real, real challenge."

Mifepristone, a drug used in abortion care, at the MAP's office in Massachusetts. The drug is inside orange boxes that have a white outline of a woman on the front.

Mifepristone, a drug used in abortion care, at the MAP's office in Massachusetts. Elissa Nadworny/NPR hide caption

His organization has been looking for the right individual or circumstance to challenge shield laws directly in court. Three Republican-led states recently tried to sue the Food and Drug Administration over regulations allowing doctors to send pills through the mail, but the Supreme Court threw out the case in June over issues of standing . Those plaintiffs say they'll fight on. And a Republican attorney general in Arkansas sent a cease-and-desist letter to a shield law provider.

Demonstrators hold an abortion-rights rally outside the Supreme Court on March 26 as the justices of the court heard oral arguments in Food and Drug Administration v. Alliance for Hippocratic Medicine.

Abortion providers back to ‘business as usual’ after high court's mifepristone ruling

Seago thinks many conservative prosecutors have been hesitant to take legal action, especially in an election year. But he says it's important to act quickly, before abortion by mail becomes pervasive.

The people who are sending these pills know that there's risk in what they're doing. Some providers say they won't travel to or through states with bans so that they can't be subpoenaed, be served legal papers or even be arrested if there's a warrant. That may mean avoiding layovers at Dallas Love Field airport or a detour around those places on a cross-country road trip. For Foster, it means she can't visit her mom and stepdad, who retired to South Carolina.

"The thing about shield laws is that they're new, so we don't have a precedent to go off of," says Lauren Jacobson, a nurse practitioner who prescribes abortion medication through Aid Access, the largest of the four shield law providers. She says she avoids large swaths of the United States. "We don't really know what will or won't happen. But I'm not going to Texas. I've been before though, so that's OK for me."

The image shows a bright blue sky and fluffy clouds above the Supreme Court building in the background, and protestors holding blue signs with white type that read,

Abortion bans still leave a 'gray area' for doctors after Idaho Supreme Court case

Shield laws don't offer blanket protection. The doctors and nurse practitioners who prescribe the pills have malpractice insurance in their states, but it's unclear whether those policies would cover suits from states with abortion restrictions. Patients use third-party payment services like Cash App or PayPal, which are also untested in how they would work under a shield law. Would they give up information on a provider or patient if requested to do so by law enforcement?

How the experience looks

Lauren, who is 33 and lives in Utah, got pregnant while on birth control and decided that she couldn't afford another child. (NPR is not using her last name because she's worried about professional repercussions.)

Abortion is legal in Utah until 18 weeks, but there are only a handful of clinics in the state. The closest one to Lauren was several hours away by car. Several years prior, she had an abortion at a clinic in Salt Lake City, and it hadn't been a pleasant experience — she had to walk through protesters. The guilt from her conservative Christian upbringing was overwhelming.

This photo shows shipping boxes that contain abortion medication.

Shield law practices account for about 10% of abortions nationwide. There were 9,200 abortions a month provided under shield laws from January to March of this year, according to fresh data from the Society of Family Planning's WeCount project. Some researchers estimate that this number has risen since then and could be as high as 12,000 per month. Elissa Nadworny/NPR hide caption

"I got in my car and I cried," she recalls. "I just never wanted to go through it again."

This time, Lauren got pills from Aid Access, a shield law provider similar to the MAP. "I was a little bit sketched out, I won't lie," she says. "Because like, well, where is this coming from? Who is this under? How are they prescribing this?"

She and her partner did research to try to figure out whether what they were doing was legal. She says ultimately she couldn't find anything that clearly stated that what she wanted to do — have pills sent from an out-of-state doctor — was illegal.

She filled out a form online with questions about how far along she was and her medical history and then connected with a doctor via email and text messages. She googled the doctor, who she found was legit and practicing out of New York.

A few days later, she received abortion medication in the mail and had her abortion at home.

"To do it in the privacy of your own home, where I felt more support as opposed to going through protesters," Lauren says. "Especially with a provider within the state of Utah. I feel like there's always a judgmental indication or undertone."

The online doctor also followed up to make sure everything had gone OK, which Lauren appreciated. "I felt it was a little bit more thorough," she says. "They're checking in on you, like, 'How did you respond? What symptoms? What's going on?'"

A staff member of the MAP brings the boxes containing abortion medication to the local post office. The person is carrying one sack with each hand, and each sack is filled with shipping boxes.

A staff member of the MAP brings the boxes containing abortion medication to the local post office. Elissa Nadworny/NPR hide caption

In Massachusetts, the folks who run the MAP hear much the same from their patients. Many emails and messages are logistical, like this email: "I took the first pill on Friday and all the other pills on Saturday. For how long should I be bleeding as I'm still bleeding this morning?"

Many others offer disbelief, relief and gratitude. "I just wanted to say thank you so much," wrote one woman. "I was terrified of this process. It goes against everything I believe in. I'm just not in a place where I can have a child. Thank you for making the pills easily accessible to me."

When Foster, who runs operations for the MAP, does a final tally of the patients who are ready to have their pills sent out, she notices a new note from a woman who just paid, bringing the day’s total number of patients from 20 to 21.

"I am a single mother on a fixed income, and I can not afford a kid right now."

It's from a woman in Alabama who is six weeks pregnant and filled out her form around lunchtime. Within an hour, a MAP doctor had reviewed her case and prescribed her the medication. She paid the fee as soon as she was approved. All in all, the whole process took about three hours. Foster is able to pack up those pills and add them to the batch headed to the post office.

By 3 p.m., the Alabama woman's package is scanned by the Postal Service worker.

It's expected to arrive by the week's end.

abortion drugs
mifepristone
abortion provider
misoprostol
Dobbs v Jackson Women's Health Organization
Roe v. Wade

IMAGES

Opinion
Summary and Conclusions
😱 Introduction about abortion research paper. Research Paper Sample on
Account of the environment a medical social worker looks at the new
Introduction abortion research paper
😝 Pro abortion paper. Abortion Essay Examples (Pros and Cons). 2022-10-27

COMMENTS

A research on abortion: ethics, legislation and socio-medical outcomes. Case study: Romania
Abstract. This article presents a research study on abortion from a theoretical and empirical point of view. The theoretical part is based on the method of social documents analysis, and presents a complex perspective on abortion, highlighting items of medical, ethical, moral, religious, social, economic and legal elements.
Impact of abortion law reforms on women's health services and outcomes
A literature review contextualizing medication abortion in seven African countries reported that incidence of medication abortion is low despite being a safe, effective, and low-cost abortion method, likely due to legal restrictions on access to the medications . Over the past two decades, many LMICs have reformed their abortion laws [3, 28 ...
Abortion Care in the United States
Abortion services are a vital component of reproductive health care. Since the Supreme Court's 2022 ruling in Dobbs v.Jackson Women's Health Organization, access to abortion services has been increasingly restricted in the United States. Jung and colleagues review current practice and evidence on medication abortion, procedural abortion, and associated reproductive health care, as well as ...
Abortion in legal, social, and healthcare contexts
We were pleased by the enthusiastic response to our Call for Papers. We note that Eklund and Purewal (2017, ... Jane", a feminist collective in Chicago, safely performed over 11,000 abortions between 1969 and 1973, prior to the legalization of abortion in the state of Illinois (Joffe, Weitz, & Stacey, 2004).
The Effect of Abortion Legalization on Fertility, Marriage, and Long
the impacts of abortion legalization laws has focused either on the short-term effects on fertility, or on the short and long-term effects on children born after a given reform. ... Most of those papers conclude that access to abortion reduces fertility. The effects are generally concentrated among teens and poorer women (Bailey and Lindo 2017).
Women's Awareness and Knowledge of Abortion Laws: A Systematic Review
Awareness and knowledge of legal grounds for abortion. Further assessing women's knowledge of the law by testing whether they were able to identify the specific legal grounds on which abortion was permitted in their respective countries was carried out in thirteen studies from 7 countries [9-11, 13-16, 20, 21, 23, 26, 29, 31].
Mental Health Implications of Abortion Restrictions for Historically
Legal abortion is a safe clinical procedure, with extremely low rates of complications and death. 1 Conversely, the risk of death associated with childbirth is 14 times that associated with legal ...
What can economic research tell us about the effect of abortion access
Multiple research teams have replicated the essential finding that abortion legalization substantially impacted American fertility while extending the analysis to consider other outcomes. 4 For ...
Access to safe abortion is a fundamental human right
Abortion is a common medical or surgical intervention used to terminate pregnancy. Although a controversial and widely debated topic, approximately 73 million induced abortions occur worldwide each year, with 29% of all pregnancies and over 60% of unintended pregnancies ending in abortion. Abortions are considered safe if they are carried out using a method recommended by WHO, appropriate to ...
Abortion Policy in the United States: The New Legal Landscape and Its
Policy Points. The historic 2022 Supreme Court Dobbs v Jackson Women's Health Organization decision has created a new public policy landscape in the United States that will restrict access to legal and safe abortion for a significant proportion of the population.; Policies restricting access to abortion bring with them significant threats and harms to health by delaying or denying essential ...
Impact of abortion law reforms on women's health services and outcomes
A country's abortion law is a key component in determining the enabling environment for safe abortion. While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, with the majority of them moving away from an absolute ban. However, the implications of these reforms on women's access to and use of health ...
PDF Abstract
From 1970 to 1980, legal abortion is estimated to have pre- vented 1500 pregnancy-related deaths and thousands of other complications. The availability of safe abortion also accounts for much of the decline in infant mortality.3 Focusing on abortion experiences, however, especially those of young and low-income women, presents a very dif- ...
Improving measures of access to legal abortion: A validation study
Background Global mechanisms have been established to monitor and facilitate state accountability regarding the legal status of abortion. However, there is little evidence describing whether these mechanisms capture accurate data. Moreover, it is uncertain whether the "legal status of abortion" is a valid proxy measure for access to safe abortion, pursuant to the global goals of reducing ...
Knowledge and attitude of women towards the legalization of abortion in
Unsafe abortion contributes to maternal deaths 13% globally and 25-35% of Ethiopia. By considering the problem of unsafe abortion, Ethiopia amended a law that permits abortion under certain circumstances. However, the country liberalized the service, women are still not using it. Therefore, the possible reason might be a lack of knowledge and attitude is a barrier that hinders women to use ...
Research Shows Access to Legal Abortion Improves Women's Lives
Abortion access improves women's overall and economic well-being. Summarized in an amicus brief (PDF) filed by more than 150 economists, research shows access to abortion improves women's economic well-being.The Turnaway Study found women who received an abortion were less likely than those denied an abortion to experience financial hardship, receive public assistance, live in poverty, or ...
PDF Abortion in The United States
legal status of abortion at the federal level. With Justice Kavanaugh's confirmation, the court has a strong conservative majority which has the potential to have a lastingimpact on abortion access in the United States. Research shows that abortion is a routine medical procedure, and restricting legal access
Abortion Experiences, Knowledge, and Attitudes Among Women in the U.S
In contrast, slightly less than half (48%) of Republican women of reproductive age think abortion should be legal, 36% say abortion should be illegal in most cases and 17% say abortion should be ...
Is Abortion Law in the US Changed Forever?
Ziegler, a 2023-24 Guggenheim fellow, researches the legal history of struggles around abortion and other reproductive health issues. Since last year, there have already been six ballot initiative struggles, more than half a dozen state Supreme Court challenges and additional fights in federal court aimed at limiting or even ending access to ...
The Effect of Legalization of Abortion on Population Growth and Public
plus illegal, 1975. increased about 123 40 percent. The Effect of Abortion Legalization. from FY 1970 (the 12-month period end-ing June 30) to FY 1972, allowing for a small number of legal abortions in the. earlier year, and a small residual of illegal abortions in the later year. The number of live births in New York.
The loss of abortion rights in the USA: the history and impacts
In March, 2024, France became the first country to enshrine the right to abortion care in its constitution. French officials cited the US Supreme Court's June, 2022 decision in Dobbs v Jackson Women's Health Organization, which eliminated federal protections for abortion care, as a key motivation. In describing the proactive decision to guarantee abortion as a right in France's constitution ...
The Impact of Legalized Abortion on Crime
DOI 10.3386/w8004. Issue Date November 2000. We offer evidence that legalized abortion has contributed significantly to recent crime reductions. Crime began to fall roughly 18 years after abortion legalization. The 5 states that allowed abortion in 1970 experienced declines earlier than the rest of the nation, which legalized in 1973 with Roe v ...
Dobbs and Democracy by Katherine Shaw, Melissa Murray :: SSRN
With this in mind, the Dobbs majority's settlement of the abortion question is unlikely to be a lasting one. Indeed, aspects of the opinion suggest that this settlement is merely a way station en route to a more permanent resolution — the recognition of fetal personhood and the total abolition of legal abortion in the United States.
The Safety and Quality of Abortion Care in the United States
1 Introduction. When the Institute of Medicine (IOM) 1 issued its 1975 report on the public health impact of legalized abortion, the scientific evidence on the safety and health effects of legal abortion services was limited ().It had been only 2 years since the landmark Roe v.Wade decision had legalized abortion throughout the United States and nationwide data collection was just under way ...
Survey shows broad opposition to abortion restrictions among women of
Abortion is legal in Arizona up to 15 weeks, but in April, the state Supreme Court ruled that an 1864 law banning all abortions except to save a woman's life was enforceable. Gov.
Abortion Law and Policy Around the World
Abortion Law and Policy Around the World. The aim of this paper is to provide a panoramic view of laws and policies on abortion around the world, giving a range of country-based examples. It shows that the plethora of convoluted laws and restrictions surrounding abortion do not make any legal or public health sense.
Legalized Abortion and the Public Health: Report of a Study
When the mortality risk of legal abortion is examined by length of gestation it becomes apparent that the mortality risks increase not only from the first to the second trimester, but also by each week of ges- tation. For example, during 1972-73, the mortality ratio for legal abortions performed at eight weeks or less was 0.5, and for those ...
PDF The effect of abortion legalization on fertility, marriage and long
subsidized, legal abortion by exploiting the Spanish legalization of abortion in 1985. Using birth records and survey data, we find robust evidence that the legalization led to an immediate decrease in the number of births to women aged 21 and younger. This effect was driven by provinces with a higher supply of abortion services. In those
Arizona and Missouri to vote on abortion rights in November
The certification of the abortion ballot initiative comes months after a national debate over an 1864 Arizona law that banned nearly all abortions in the state.. Arizona's Supreme Court reinstated ...
For Abortion Providers, a Tough Business Gets Even Tougher
Three of the 36 states (and Washington, D.C.) where abortion is legal, limit the use of private insurance to cover services in their state-regulated plans. Twelve states also ban abortion coverage ...
Meet the people sending abortion pills to places with bans : NPR
A few days later, she received abortion medication in the mail and had her abortion at home. "To do it in the privacy of your own home, where I felt more support as opposed to going through ...