OriginalResearchArticleinTheLancetAuthorVersion

Inducedabortion:incidenceandtrendsworldwide from1995to2008

*GSedghScD,SSinghPhD,SKHenshawPhD,ABankolePhD:Guttmacher Institute,NewYork,NYUSA IHShahPhD,EhmanMA:WorldHealthOrganization,Geneva,Switzerland

PublishedonlineJanuary,19th,2012
DOI:10.1016/S01406736(11)617868

AbstractavailableonTheLancetWebsite
*CorrespondingAuthor: Dr.GildaSedghScD GuttmacherInstitute 125MaidenLane,7thFloor NewYork,NY10038 phone:212.248.1111fax:212.248.1951 gsedgh@guttmacher.org

DeclarationofConflictingInterests Wedeclarethatwehavenoconflictsofinterest.

Abstract
Background Dataofabortionincidenceandtrendsareneededtomonitorprogresstoward improvementofmaternalhealthandaccesstofamilyplanning.Todate, estimatesofsafeandunsafeabortionworldwidehaveonlybeenmadefor1995 and2003. Methods WeusedthestandardWHOdefinitionofunsafeabortions.Safeabortion estimateswerebasedlargelyonofficialstatisticsandnationallyrepresentative surveys.Unsafeabortionestimateswerebasedprimarilyoninformationfrom publishedstudies,hospitalrecords,andsurveysofwomen.Weusedadditional sourcesandsystematicapproachestomakecorrectionsandprojectionsas neededwheredataweremisreported,incomplete,orfromearlieryears.We assessedtrendsinabortionincidenceusingratesdevelopedfor1995,2003,and 2008withthesamemethodology.Weusedlinearregressionmodelstoexplore theassociationofthelegalstatusofabortionwiththeabortionrateacross subregionsoftheworldin2008. Findings Theglobalabortionratewasstablebetween2003and2008,withratesof29and 28abortionsper1000womenaged1544years,respectively,followingaperiod ofdeclinefrom35abortionsper1000womenin1995.Theaverageannual percentchangeintheratewasnearly2.4%between1995and2003and0.3% between2003and2008.Worldwide,49%ofabortionswereunsafein2008, comparedto44%in1995.Aboutoneinfivepregnanciesendedinabortionin 2008.Theabortionrateislowerinsubregionswheremorewomenliveunder liberalabortionlaws(p<0.05). Interpretation Thesubstantialdeclineintheabortionrateobservedearlierhasstalled,andthe proportionofallabortionsthatareunsafehasincreased.Restrictiveabortion lawsarenotassociatedwithlowerabortionrates.Measurestoreducethe incidenceofunintendedpregnancyandunsafeabortion,includinginvestmentsin familyplanningservicesandsafeabortioncare,arecrucialstepstowardachieving theMillenniumDevelopmentGoals.

Introduction
Informationonglobalandregionalabortionratesandtrendscanhelpidentify gapsincontraceptiveuse.Althoughabortionsdoneaccordingtomedical guidelinescarryverylowriskofcomplications,[13]unsafeabortionscontribute substantiallytomaternalmorbidityanddeathworldwide.[46]Monitoring abortiontrendsisthuscrucialtoassessimprovementofmaternalhealth,andthe progresstowardtheUNMillenniumDevelopmentGoal5(MDG5),toreduce maternalmortalityandachieveuniversalaccesstoreproductivehealth. Moreover,oneofthemanycontroversiessurroundingabortioniswhether restrictiveabortionlawspreventwomenfromobtainingabortions.Analysesof theassociationbetweenabortionincidenceandthelegalstatusofabortioncan clarifywhetherlawisafactorthataffectsabortionincidence. However,abortionsarenotdocumentedincountrieswithhighlyrestrictive abortionlawsandareoftenunderreportedelsewhere,especiallywherethe practiceishighlystigmatized.Therefore,estimationofregionalandglobal incidencerequirescompilationofinformationfromarangeofsourcesandcareful assessmentofinformationforqualityandcompleteness.Variousdatasources andestimationapproacheshavebeenassessed,refined,andappliedoverthe years,andarenowwidelyacceptedassourcesofreasonablenationalestimates. [4,79] Weestimatedtheincidenceofsafeandunsafeabortiongloballyandinallthe majorregionsandsubregionsoftheworldin2008.Weassessedtrendssince 1995and2003,theonlyotheryearsforwhichsimilarassessmentsweredone. Wealsoexaminetheassociationsofabortionincidencewiththelegalstatusof abortionacrosstheworldssubregions.

Methods
Definitionsanddatasources WeadheredtothedefinitionofunsafeabortionestablishedbyWHO,namely,a procedureforterminationofanunintendedpregnancydoneeitherbypeople lackingthenecessaryskillsorinanenvironmentthatdoesnotconformto minimummedicalstandards,orboth.[10]AselaboratedbyWHO,[4,11] abortionsdoneoutsidetheboundsoflawarelikelytobeunsafeeveniftheyare

donebypeoplewithmedicaltrainingforseveralreasons:suchproceduresare usuallydoneoutsidefacilitiesauthorizedtoperformabortions,sometimesin unsanitaryconditions;thewomanmightnotreceiveappropriatepostabortion care;medicalbackupisunlikelytobeimmediatelyavailableshouldan emergencyarise;andthewomanmightdelayseekinganabortionorseekingcare forcomplicationsbecausetheabortionisclandestine.Thus,asinpreviousefforts toestimateabortionincidenceandconsistentwithWHOpractice,weusedthe operationaldefinitionofunsafeabortions,whichisabortionsdoneincountries withhighlyrestrictiveabortionlaws,andthosethatdonotmeetlegal requirementsincountrieswithlessrestrictivelaws.Safeabortionsweredefined asthosethatmeetlegalrequirementsincountrieswithliberallaws,orwherethe lawsareliberallyinterpretedsuchthatsafeabortionsaregenerallyavailable. Countrieswithliberallawsweredefinedasthosewhereabortionislegalon requestoronsocioeconomicgrounds,eitherwithorwithoutgestationallimits; andcountrieswhoselawsallowforabortiontopreservethephysicalormental healthofthewoman,iftheselawswereliberallyinterpreted,asof2008.Tothe bestofourknowledge,HongKongSpecialAdministrativeRegion,Israel,New Zealand,SouthKorea,Spain,andEthiopiametthelattersetofcriteria.The classificationofcountriesaccordingtowhethertheirabortionlawsareliberalor restrictiveisreviewedelsewhere.[12]Althoughthelegalstatusofabortionand riskassociatedwiththeprocedurearenotperfectlycorrelated,itiswell documentedthatmorbidityandmortalityresultingfromabortiontendtobehigh incountriesandregionscharacterizedbyrestrictiveabortionlaws,[46]andis verylowwhentheseareliberal.[13] Weusedempiricalevidenceofsafeabortionsdoneoutsidetheboundsofthelaw andunsafeabortionsdonedespiteliberallawswhenthisinformationwas available.InIndia,abortionislegallypermittedandavailableunderbroad conditions,butmanyabortionsneverthelesstakeplaceoutsideofhealthservices legallyauthorizedtodoabortions;someofthesearedeemedsafeandsome unsafe.[13]InCambodia,abortionislegaluponrequestthroughthefirst trimesterofpregnancy,buthalfofallabortionsneverthelesstakeplacein womenshomesandothersettingsoutsideofformalfacilities;[14]wedeemed

suchabortionstobeunsafe.InsubSaharanAfrica,abortionlawisliberalin ZambiaandSouthAfrica,andabortionislegalifitistopreservethehealthofthe womaninsevenothercountries.WiththeexceptionofSouthAfrica,however, theselawsarelargelynotimplemented,andmostabortionsinthesecountries occurunderunsafeconditions. Some abortionsinSouthAfricaarealsostillunsafe, despitethemorewidespreadprovisionofsafeabortionservicessincethe liberalizationofabortionlawin1996.[15]Smallpercentagesofabortionsarealso knowntobeunsafeinsomeeasternEuropeanandothercountrieswithliberal lawsthatwereformerlypartoftheSovietUnion.[16]Thereisevidencethat somewomenrelyonunsafeabortionsintheUSAdespitetheliberalabortionlaw, [17,18]andthesameisprobablytrueforotherdevelopedcountrieswithliberal laws,butthesenumbersarenegligiblewheretheyhavebeenestimated. Fortheglobalestimationofbothsafeandunsafeabortions,wegatheredrelevant informationonabortionincidenceineverycountryandterritory,assessedthe qualityoftheinformation,andmadesomeadjustmentstoaccountfor misreportingandunderreporting,usuallyonthebasisofindicatorsrelatedto abortionincidenceandqualityofreporting,frompublishedstudiesandreports. Wecomputedsubregionalandregionalestimatesasthesumoftheestimatesfor allcountriesinthesegeographicalareas. Safeabortions 57ofthe84countriesandterritorieswithliberalabortionlawshaveamechanism forcollectionofstatisticsaboutproceduresdone.Statisticsfor2008were obtainedmainlyfrompublishedandunpublishedreports,websitesofofficial nationalreportingagencies,andquestionnairesgiventosuchagenciesbythe studyteam. Weassessedthequalityofofficialreportsusingfeedbackfromagencies implicatedindatacollectionandfromexpertswhowerefamiliarwithreportingof abortioninthecountries,includingdemographersandsocialscientists,and programmanagers,providers,andpolicyadvisersfamiliarwithproceduresof reportingofabortionsineachcountry.Issuesthataffectabortionreportingand

assessmentsofthequalityofreportsfromspecificcountrieshavebeen comprehensivelyreviewedelsewhere,[7,19]andtheseresourcesalsoservedas theevidencebaseforadjustmentstothenationalfigures.Whereexpertsdeemed thatstatisticsincludedatleast95%ofallabortionprocedures,asinseveral northernandwesternEuropeancountries,noadjustmentsweremadetothese reports.Forcountrieswithincompletestatistics,weusedthesamecorrection factorusedtoestimateincidencein2003,whenwedidnothavesufficient evidenceofachangeincompletenessofreporting.Thecorrectionfactorsapplied toofficialstatisticsrangedfrom1.05to2.54(indicatingthatthereported numberswereincreasedby5154%),andtheaverageofthecorrectionfactors was1.26. Forsixcountrieswithliberallaws,abortionestimateswereonlyavailablefrom nationallyrepresentativesurveysofwomendonewithin5yearsoftheyearof estimation.Therateofunderreportingfromsuchsurveysrangedfrom15%to 69%accordingtostudiesthatwereabletovalidatetheirfindings.[9,20,21]With nosuchstudiesvalidatingfindingsforthesesixspecificcountries,weadjusted surveyestimatesupwardby20%toaccountfortheminimumexpecteddegreeof underreporting.Forseveralcountries,bothsurveybasedestimatesand incompleteofficialreportswereavailable.Weprojectedadjustedsurveybased estimatesforyearsearlierthan2008to2008usingtrenddatafromofficial reports.Whennoevidenceofachangeintheabortionrateovertimewas available,eitherfromofficialreportsorothersources,weappliedto2008the ratefortheyearnearestto2008. For13countriesandminorterritorieshavingnoabortionstatisticsorestimates, including2%ofthefemalepopulationincountrieswithpredominantlysafe abortion,weappliedalowvariant(10abortionsper1000women),medium variant(20abortionsper1000women),orhighvariantabortionrate(50 abortionsper1000women),basedontheircontraceptiveprevalenceandfertility rates,andinferencesdrawnfrominformationofabortioninsimilarsettings.

 Unsafeabortions Thecompilationofstudiesanddataonunsafeabortionisanongoingactivityof WHOsSpecialPrograminHumanReproduction.Toestimateabortionincidence, wegatheredinformationfrompublishedandunpublishedsourcesobtainedfrom websitesofnationalauthoritiesandnongovernmentalorganizations,data reportedtoWHOHeadquartersandRegionalOffices,searchesoflibrary databases,andthroughpersonalcontactswithresearchersworldwide.Wegave preferencetonationalestimatespublishedinpeerreviewedjournalsorother reportsusingwidelyacceptedmethodologies;whenthesereportswereabsent, weprioritizednationallyrepresentativedata,mainlyhospitalizationrecords.In theabsenceofnationaldata,weadjustedinformationfromsubnationalstudies asneededtoprovidenationalestimatesbasedoneachstudysselectioncriteria. Weappliedestimatesforyearsotherthan2008to2008whentherewasno evidencetosuggestchangesinabortionlevels.Morenationalleveldatawere availabletoinformtheestimatesfor2008thanfor1995or2003,especiallyfor westernAsia,middleAfrica,andcentralAmerica,allowingformoreaccurate estimatesforthosesubregionsin2008. Forcountrieswithavailabledataonnumbersofwomenadmittedtohospitalfor complicationsfrominducedandspontaneousabortions,wecomputedunsafe abortionincidenceusingawidelyusedtechniquethatentails(1)subtractionof thelikelynumberofspontaneousabortioncases,and(2)applicationofan adjustmentfactortoaccountfortheestimatednumberofwomenhaving abortionswhodonotneedordonotreceivetreatment.Forseveralcountries, publishedadjustmentfactorsderivedfromsurveysofknowledgeable professionalsareavailable.[22]Forothers,thefactorwasassumedtobethe sameasthatinacountrywithasimilarabortionlawandhealthcare infrastructureandaknownadjustmentfactor. Asalreadynoted,surveysofwomengenerallyunderestimateabortionincidence becausealargeproportionofwomendonotreporttheirabortions.Under reportingisevengreaterincountrieswithrestrictivelawsthanincountrieswith

liberallaws.Studiesindicatethatatmosthalfofwomenincountrieswith restrictiveabortionlawsreporttheirabortions,andweusedthisminimum adjustmentforsurveybasedestimates. For11countriesrepresenting5%ofwomenofreproductiveagelivingwhere abortionsareunsafe,weadjusteddatafromsubnationalstudiestoyieldnational estimatesbyweightingtheresultstomatchtheruralandurbancompositionof thecountry.Afewsmallcountriesforwhichnoinformationwasavailablewere assumedtohavethesameabortionrateasothercountriesintheregionwith similarabortionlaws,fertilityandcontraceptiveuse,ortheaveragerateofother countriesintheregiontowhichtheybelong. Certaintyofestimates Becausefewoftheabortionestimateswerebasedonstudiesofrandomsamples ofwomen,andbecausewedidnotuseamodelbasedapproachtoestimate abortionincidence,itwasnotpossibletocomputeconfidenceintervalsbasedon standarderrorsaroundtheestimates.Drawingontheinformationavailableon theaccuracyandprecisionofabortionestimatesthatwereusedtodevelopthe subregional,regional,andworldwiderates,wecomputedintervalsofcertainty aroundtheserates(Availableonrequestfromauthors).Wecomputedwider intervalsforunsafeabortionratesthanforsafeabortionrates.Thebasisforthese intervalsincludedpublishedandunpublishedassessmentsofabortionreporting incountrieswithliberallaws,[7,19]recentlypublishedstudiesofnationalunsafe abortion,[2325]andhighandlowestimatesofthenumbersofunsafeabortion developedbyWHO.[4]Thebodyofcountryspecificevidenceonabortionhas increasedwithtime,andmorerecentregionalandsubregionalestimateswere thereforelikelytobemoreprecisethanolderestimates. Statisticalanalysis Wecalculatedabortionrates(numbersofabortionsforevery1000womenaged 1544years)usingUNPopulationDivision(UNPD)populationestimates.[26]We

estimatedthenumberofpregnanciesasthesumoflivebirths(alsobasedon UNPDestimates),abortions,andspontaneouspregnancylosses(miscarriagesand stillbirths).Usingamodelbasedapproachderivedfromclinicalstudies,we estimatedthatspontaneouspregnancylossesequaled20%ofallbirthsplus10% ofallabortions.[27,28]RegionsweredefinedastheyarebytheUNPopulation Division.[26] Weexaminedtheassociationsoftheabortionratesintheworlds18subregions withaccesstolegalabortion,measuredasthepercentofthefemalepopulation aged1544yearslivingincountriesorterritorieswithliberalabortionlawsin 2008.Wedidunivariatelinearregressionanalysesafterensuringthatthe assumptionsoflinearregressionmodelsweremet.WeusedSPSSversion18to dothestatisticalanalyses. Roleofthefundingsource Thesponsorsofthestudyhadnoroleinstudydesign,datacollection,data analysis,datainterpretation,orwritingofthereport.Thecorrespondingauthor hadfullaccesstoallthedatainthestudyandhadfinalresponsibilityforthe decisiontosubmitforpublication.

Results
Anestimated43.8millionabortionsoccurredin2008,comparedwith41.6million in2003,and45.6in1995(table1).About78%ofallabortionstookplaceinthe developingworldin1995,andincreasedto86%in2008,whereastheproportion ofallwomenofreproductiveagewholiveinthedevelopingworldrosefrom80% to84%inthesameinterval.Since2003,thenumberofabortionsfellby0.6 millioninthedevelopedworld,butincreasedby2.8millionindeveloping countries.TheestimatedannualnumberofabortionsrosemoderatelyinAfrica andAsia,andslightlyintheLatinAmericaregion;itfellslightlyinEuropeand NorthAmericaandheldsteadyinOceania(table1). Althoughabsolutenumbersofabortionsmightincreaseasaresultofpopulation growth,theabortionrateper1000womenisnotaffectedbythisfactor.Some28 abortionsoccurredforevery1000womenaged1544yearsin2008,compared

with29in2003(table2).Takingintoaccountthecertaintyintervalsaroundthese numbers,thisdifferencewasnotdeemedmeaningful.Thisinsubstantialchangein theratefollowsaperiodofnotabledeclinefrom35abortionsper1000womenin 1995,representinganaverageannualdeclineofalmost2.4%between1995and 2003,comparedwith0.3%between2003and2008. In2008,theestimatedratewas24inthedevelopedworldand29inthe developingworld.Abortionrateshavebeenfairlystableattheregionallevelsince 2003,followingsmalldeclinesinsomeregions,mostnotablyEurope,between 1995and2003(figure1). TheabortionratesintheAfricansubregionsrangedfrom15(southernAfrica)to 38(easternAfrica)in2008(table2).Thefluctuationintheratesformiddleand southernAfricasince1995reflectsdifferencesinthequalityofdataavailableover time;thelowerrateinsouthernAfricain2008alsoprobablyreflectsinparta decreaseinabortionincidence. AbortionratesacrosstheAsiansubregionsrangedfrom26(southcentraland westernAsia)to36(southeasternAsia)in2008(table2).Thehighratein southeasternAsiaispartlyduetothehighincidenceinVietnam,whichcomprises 15%ofthepopulationinthissubregion.Theestimatedabortionratesheldsteady intheAsiansubregionsbetween2003and2008(table2). In2008,thelowestsubregionalrateworldwidewasinwesternEurope(12)and thehighestwasineasternEurope(43;table2).TheratesintheEuropean subregionswereunchangedsince2003.ThesteadyratesinEasternandSouthern Europefollowsharpdropsintheratebetween1995and2003.Theabortionrate declinedmodestlyinOceaniabetween1995and2008. Worldwide,49%ofabortionswereunsafein2008,upfrom44%in1995(table2). Nearlyall(97%)abortionswereunsafeinAfricain2008(table2).Theproportions ofabortionsthatareunsafevarywidelyacrossAsia,fromanegligibleproportion ineasternAsiato65%insouthcentralAsia(table2).Theestimatedproportionof abortionsthatareunsafeincreasedmostinwesternAsia,partlyasaresultof declinesintheincidenceofsafeabortion.Some91%ofabortionsinEuropeare

safe(table2).PracticallyalltheunsafeabortionsinEuropetakeplaceineastern Europe,where13%ofabortionswereunsafein2008. Theestimatedworldwideproportionofpregnanciesthatendinabortionwas21% in2008,20%in2003,and22%in1995(table3).Inthedevelopedworld,abortion declinedasapercentofallpregnanciesfrom36%in1995,to26%in2008.Itheld steadyat1920%ofpregnanciesinthedevelopingworld(table3).The proportionofpregnanciesthatendinabortionwaslowerindevelopingregions thanindevelopedregions,partlybecausebirthrateswerehigherindeveloping regions.Thesharpdeclineintheproportionofpregnanciesthatendedin abortioninthedevelopedworldsince1995wasconcentratedineasternEurope (datanotshown).ThisproportionalsodeclinedmodestlyinNorthAmericaand Oceania. In2008,theabortionratewaslowerinsubregionswherelargerproportionsof thefemalepopulationlivedunderliberallawsthaninsubregionswhere restrictiveabortionlawsprevailed(bcoefficientfortheassociationbasedona linearregressionmodel0.11,p<0.05;figure2).

Discussion
Ourfindingsshowthatthesubstantialdeclineintheabortionrateobserved between1995and2003hastaperedoff,andtheproportionofabortionsthatare unsafehasincreasedsince1995,suchthatnearlyhalfofallabortionsworldwide wereunsafein2008. Ourestimatesoftheratesofunsafeabortionacrosscountriesandregionstendto alignwithindependentsubnational,national,andregionalresearchofthe incidenceofabortionrelatedmorbidityandmortality,wheresuchevidence exists.However,amongtheabortionsclassifiedaseithersafeorunsafe,thereisa spectrumofriskassociatedwiththeprocedurethatdependsonfactorssuchas trainingofproviders,abortionmethodsused,andtheextenttowhichabortions aredoneunderhygienicconditions.Thisriskrangeisnotrepresentedinthe simpleclassificationsystemweusedbecausedetailedinformationaboutabortion provisionwasunavailableformostcountries.

Evidencefromvariouscountries,includingsomewithhighlyrestrictiveabortion laws,suggeststhattheuseofmisoprostolasanabortifacienthasbeenspreading. [24,2931]Althoughclandestinemedicalabortionsarelikelytobeoflowerrisk thanotherclandestineabortions,thereissubstantialvariationinmedical abortionregimensusedillegally,andcomplicationssuchasprolongedandheavy bleedingandincompleteabortionsareassociatedwithuseofincorrectdosages. [30]Thus,theseproceduresareonthewholeclassifiedasunsafe. Thesafetyofanabortionprocedureisalsoaffectedbythegestationalageatthe timeoftheabortion.Womenmightdelayseekinganabortionwhereabortion lawsarerestrictiveorabortioniswidelystigmatized,andtheprevalenceoflate abortionsmightchangewithtime.[32]Researchongestationalageatabortionis extremelyscarceandthisrepresentsagapinresearchonunsafeabortion. Statisticsonabortionincidencearepronetomisreportingformanyreasons,as elaboratedinreviewsofabortionestimationmethodologies.[8,9]Thesepotential sourcesoferrorincludeomissionofprivatesectorabortions;inclusionof spontaneousabortionsinsomeofficialreports;undercountingofmedical abortions;underreportingofinducedabortionsinsurveysofwomen,and misclassificationofabortionrelatedcomplicationsinhospitalizationrecords.We usedvarioussources,includingpublishedstudies,modelsbasedonbiological data,andinputfromkeyinformants,toassessthemagnitudeofthesebiasesand tocorrectforthem.Weexpectthattherangeofrandomerrorincountryspecific estimatesnarrowswhentheseareaggregatedtothesubregionalandregional levels.Wedevelopedcertaintyintervalstoaccountfortheremainingimprecision intheestimates. Changesinabortionincidencebetween1995and2008arenotexplainedbythe agedistributionofwomen1544worldwide.Theproportionof1544yearolds whoareaged1529years(theagerangeatwhichabortionismostprevalent) [33,34]declinedbylessthan4%overthese13years[35]whereastheabortion rateper1000womenaged1544yearsdeclinedby19%.Othertrendsthatcould affecttheabortionrate,andforwhichrepresentativedataatthesubregionaland regionallevelsarenotreadilyavailable,includeariseinwomensageatmarriage,

increasedprevalenceofsexualactivityamongunmarriedwomen,andgrowing proportionsofwomeninthelaborforceresultinginmoreprevalentandmore stronglyhelddesirestocontrolthetimingofbirths. Wefoundthattheproportionofwomenlivingunderliberalabortionlawsis inverselyassociatedwiththeabortionrateinthesubregionsoftheworld.Other studieshavefoundthatabortionincidenceisinverselyassociatedwiththelevel ofcontraceptiveuse,especiallywherefertilityratesareholdingsteady,[3638] andthereisapositivecorrelationbetweenunmetneedforcontraceptionand abortionlevels.[36]Theunmetneedformoderncontraceptionislowerin subregionsdominatedbyliberalabortionlawsthaninthosedominatedby restrictivelaws,andthismighthelpexplaintheobservedinverseassociation betweenliberallawsandabortionincidence.[39]Globallevelsofunmetneed andcontraceptiveuseseemtohavestalledinthepastdecade:thepercentof marriedwomenwithunmetneedforcontraceptionfellby02percentagepoints peryearin19902000,butessentiallydidnotchangein20002009.[39]Family planningservicesseemtonottobekeepingupwiththeincreasingdemand drivenbytheincreasinglyprevalentdesireforsmallfamiliesandforbetter controlofthetimingofbirths.[40] ThemostrecentprogressreportontheMDGsshowsthatthegapbetween developedanddevelopingcountriesislargestwithrespecttomaternalhealth. [41]Thisgapismirroredinthesharpdifferenceintheincidenceofunsafe abortionbetweenthedevelopedanddevelopingregions.Withindeveloping countries,moreliberalabortionlawsareassociatedwithfewerhealth consequencesfromunsafeabortion.Abortionmortalityfellgreatlyafterthe liberalizationoftheabortionlawinSouthAfrica.[42,43]InNepal,whereabortion wasmadelegalonbroadgroundsin2002,abortionrelatedcomplicationsfell from54%to28%ofallmaternalmorbiditiestreatedatrelevantfacilitiesbetween 1998and2009.[44]Recentnationaltrendsinabortionrelatedmorbidityand mortalityinEthiopia,wherethelawwasliberalizedin2005,arenotyetknown, butaccesstoequipmentandtrainingofprovidersinsafeabortioncareincreased since2005,[45]andastudyinonelargehospitalfoundthattheratioofabortion complicationstolivebirthsdeclinedsignificantlybetween2003and2007.[46]

Variousdevelopingcountrieshavebroadenedthegroundsunderwhichabortion islegalinrecentyears.[47]However,aliberalabortionlawalonedoesnotensure thesafetyofabortions.Othernecessarystepsincludethedisseminationof knowledgeaboutthelawtoprovidersandwomen,thedevelopmentofhealth serviceguidelinesforabortionprovision,thewillingnessofproviderstoobtain trainingandprovideabortionservices,andgovernmentcommitmenttoprovide theresourcesneededtoensureaccesstoabortionservices,includinginremote areas. Althoughresearchindicatesthattheannualnumberofmaternaldeathshas declinedinrecentyears,theWHOestimatesthattheproportionofmaternal deathsduetounsafeabortionremainedat13%in2008asin2003.[4]Deathdue tounsafeabortionremainsanimportantandavoidableoccurrence,asdothe healthandsocialandeconomicconsequencesofunsafeabortion.[12,48] Constraintsonaccuratelymeasuringabortionlevelshavebecomemoreprevalent overtheyearswhereprivatesectorabortions,medicalabortions,andthe stigmatizationofabortionhavebecomemorecommon,asallthesefactorstend toincreasethelevelofunderreporting.Ifabortionestimationistoremain feasible,investmentsmustbemadeinfurtherrefiningandapplyingresearch methodsformeasuringabortionincidence. Wefoundthatabortionscontinuetooccurinmeasurablenumbersinallregions oftheworld,regardlessofthestatusofabortionlaws.Unintendedpregnancies occurinallsocieties,andsomewomenwhoaredeterminedtoavoidan unplannedbirthwillresorttounsafeabortionsifsafeabortionisnotreadily available,somewillsuffercomplicationsasaresult,andsomewilldie.Measures toreducetheincidenceofunintendedpregnancyandunsafeabortionincluding improvingaccesstofamilyplanningservicesandtheeffectivenessof contraceptiveuse,andensuringaccesstosafeabortionservicesandpost abortioncarearecrucialstepstowardachievingtheMDGs.

Contributors GSandEAcompiledinformationsourcesandledtheestimationoftheincidence ofsafeabortion(GS)andunsafeabortion(EA).SS,IHS,SKH,andABprovided technicalassistanceduringthedatacollectionandestimationofabortion incidence.GSwroteandrevisedthereport.Allotherauthorsprovided substantiveinputondraftsofthereport.Allauthorshaveseenandapprovedthe finalversionofthereport. Acknowledgments ThisstudywasfundedbytheUKDepartmentofInternationalDevelopment,the DutchMinistryofForeignAffairs,andtheJohnDandCatherineTMacArthur Foundation.Theestimationofunsafeabortionwasdevelopedandcommissioned byWHOandsomeoftheseestimateshavebeenpublishedpreviously.4The estimationofsafeabortionandthecompilationofworldwidelevelswasledby theGuttmacherInstitute.Theauthorsaloneareresponsiblefortheviews expressedinthispaperandtheydonotnecessarilyrepresentthedecisions, policy,orviewsoftheirinstitutionsorthoseoffundingagencies.WethankAlyssa Tartaglione,RubinaHussain,andMichelleEilersfortheirassistancewith obtainingandmanagingdataandpreparingthemanuscript.

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Table 1. Estimated number of induced abortions (in millions) worldwide and by region, subregion and year. Region and Subregion World Developed countries (2) Excluding Eastern Europe Developing countries Excluding China
(2) (1)

2008 43.8 6.0 3.2 37.8 28.6

2003 41.6 6.6 3.5 35.0 26.4

1995 45.6 10.0 3.8 35.5 24.9

Estimates by region and subregion Africa Eastern Africa Middle Africa Northern Africa Southern Africa Western Africa Asia Eastern Asia South-central Asia South-eastern Asia Western Asia Europe Eastern Europe Northern Europe Southern Europe Western Europe Latin America Caribbean Central America South America Northern America Oceania
1 2

6.4 2.5 0.9 0.9 0.2 1.8 27.3 10.2 10.5 5.1 1.4 4.2 2.8 0.3 0.6 0.4 4.4 0.4 1.1 3.0 1.4 0.1

5.6 2.3 0.6 1.0 0.3 1.5 25.9 10.0 9.6 5.2 1.2 4.3 3.0 0.3 0.6 0.4 4.1 0.3 0.9 2.9 1.5 0.1

5.0 1.9 0.6 0.6 0.2 1.6 26.8 12.5 8.4 4.7 1.2 7.7 6.2 0.4 0.8 0.4 4.2 0.4 0.9 3.0 1.5 0.1

Regions and subregions as defined by the United Nations.

Developed regions are defined here to include Europe, North America, Australia, Japan and New Zealand; all others are classified as developing.

Table 2. Estimated safe and unsafe abortion rates* worldwide and by region, subregion and year. 2008 Safe Unsafe % Unsafe 14 22 17 13 8 14 1 ^ 16 22 49 6 ^ 56 74 2003 Safe Unsafe % Unsafe 15 24 18 13 8 14 2 1 16 22 47 7 3 55 73 1995 Safe Unsafe % Unsafe 20 35 20 16 8 15 4 1 18 25 44 9 3 54 76

Region and Subregion World Developed countries Excluding Eastern Europe Developing countries Excluding China Estimates by region and subregion Africa Eastern Africa Middle Africa Northern Africa Southern Africa Western Africa Asia Eastern Asia South-central Asia South-eastern Asia Western Asia Europe Eastern Europe Northern Europe Southern Europe Western Europe Latin America Caribbean Central America South America Northern America Oceania

Total 28 24 17 29 29

Total 29 25 19 29 30

Total 35 39 20 34 33

29 38 36 18 15 28 28 28 26 36 26 27 43 17 18 12 32 39 29 32 19 17

1 2 ^ ^ 7 ^ 17 28 9 14 11 25 38 17 18 12 2 21 ^ ^ 19 14

28 36 36 18 9 28 11 ^ 17 22 16 2 5 ^ ^ ^ 31 18 29 32 ^ 2

97 96 100 98 58 100 40 ^ 65 61 60 9 13 ^ ^ ^ 95 46 100 100 ^ 15

29 39 26 22 24 27 29 28 27 39 24 28 44 17 18 12 31 35 25 33 21 18

^ ^ ^ ^ 5 ^ 18 28 9 16 16 25 39 17 15 12 1 19 ^ ^ 21 15

29 39 26 22 18 27 11 ^ 18 23 8 3 5 ^ 3 ^ 30 16 25 33 ^ 3

98 100 100 100 77 100 38 ^ 66 59 34 11 12 ^ 18 ^ 96 45 100 100 ^ 16

33 41 35 17 19 37 33 36 28 40 32 48 90 18 24 11 37 50 30 39 22 21

^ ^ ^ 1 ^ ^ 21 36 6 16 18 43 78 17 22 11 2 27 ^ ^ 22 17

33 41 35 17 19 37 12 ^ 22 24 13 6 12 1 3 ^ 35 23 30 39 ^ 5

99 100 100 96 100 100 37 ^ 78 60 42 12 13 8 12 ^ 95 47 100 100 ^ 22

* Abortions per 1,000 women aged 15-44.

^ Rate or percent less than 0.5.

Table 3. Estimated percent of all pregnancies* that ended in abortion, worldwide and by region, subregion and year.

Region and Subregion World Developed countries Excluding Eastern Europe Developing countries Excluding China Estimates by region Africa Asia Europe Latin America Northern America Oceania

2008 21 26 17 20 18

2003 20 28 19 19 17

1995 22 36 20 20 16

13 22 30 25 19 14

12 22 32 22 21 16

12 21 42 23 22 17

*Pregnancies include live births, abortions and miscarriages.

Figure1.Trendsinabortionratebygeographicregion,1995 to2008
Abortionsper1,000women1544

60 50 40 30 20 10 0 1990 1995 2000 Year 2005 2010

Africa Asia Europe LatinAmerica NorthernAmerica Oceania

Figure2.Theassociationoftheabortionratewiththe prevalenceofliberalabortionlawsbysubregion,2008.
60 50 40 30 20 10 0 0 20 40 60 80 100 %ofwomen1544livingunderliberalabortionlaws

Abortionsper1,000women1544