BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8161 (Published 4 December 2012)
by Sophie Arie, freelance journalist mail@sophiearie.com
Sophie Arie examines the differences in approach to abortion around the
world
Abortion has always been a subject for passionate public debate. But
recently the temperature has risen, especially in the United States and
Ireland. The Republic of Ireland has seen nationwide protests over the
death of Savita Halappanavar, who was refused an abortion during a long
and painful miscarriage because the fetus was still alive. After the
fetus was finally removed she died of septicaemia and organ failure. The
debate has also been reopened in the UK, where health minister Jeremy
Hunt recently declared a desire to see the limit in England, Wales, and
Scotland drop from 24 weeks to 12 and the prime minister expressed an
interest in a more modest reduction.
In recent decades, abortion has become legal in all but five countries
if a mother’s life is threatened. There has also been a general decline
in the numbers of abortions worldwide as contraception has become more
widely available. But World Health Organization figures show that the
decline has slowed recently. So what’s going on? Is there a general
shift towards tighter restrictions? Are people being discouraged from
using family planning as populations dwindle? And is that forcing more
women to take clandestine routes to terminate unwanted pregnancies?
Ireland
Abortion is illegal under most circumstances in both the Republic of
Ireland and Northern Ireland: it is allowed only when a mother’s life is
in danger or her long term health seriously at risk. In Northern
Ireland, the process for approving an abortion is very strict: two
doctors must agree independently that the mother’s health is at risk and
the abortion must take place within nine weeks of that decision. The NHS
carries out between 30 and 50 abortions a year in Northern Ireland,1 and
last year 1007 women travelled to other UK countries for abortions.2 In
October, Marie Stopes opened the country’s first private abortion clinic
in Belfast. The organisation says it plans to work within Northern
Ireland’s legal framework, but anti-abortion groups say it aims to widen
access to abortion on mental health grounds.3
In the Republic of Ireland the circumstances in which a woman’s life is
deemed to be at risk are not entirely clear, and the recent case of
Savita Halappanavar highlighted the fact that even when a woman’s life
is threatened some doctors or institutions do not consider abortion an
option. At least 4149 Irish women made the journey to the UK for
abortions in 2011.2 Ireland is currently revising its guidelines on what
constitutes a risk to a woman’s health after three women challenged the
country’s constitution in the European Court of Human Rights.4
Anti-abortion groups argue that there are always ways to protect a
woman’s health without carrying out an abortion and fear that the new
regulations will be the first step towards widening access to abortion.
China
China’s single child policy means that there are an estimated 13 million
abortions annually—making it the country with by far the highest
number.5 The numbers are thought to have been rising since 2003, after a
long period of decline, which has been attributed to increased
premarital sex, disruptions in access to contraceptive services because
of rapid urbanisation, and a lack of condom culture (six million
abortions are in women under 25).6 However, the rapid changes in China
have brought growing pressure for a change to the way the one child
policy is enforced. Activists monitoring the policy say that
instructions have been given to local authorities not to carry out late
term forced abortions after one case involving a seven month pregnant
woman caused national and international outcry this summer.7
India
Abortion is legal in India to protect the mother’s health, after rape,
in insane women and underaged girls, or if the fetus has serious
malformations. It is not legal as a way to avoid giving birth to a girl.
There are hefty fines for those offering sex tests or abortions for sex
selection. But India’s 2011 census showed a growing imbalance between
the numbers of girls and boys aged 0-6 years, which research suggests is
due to an increase in selective abortion of female fetuses.8 The
government has so far failed to change or control the culture that
prizes boys over girls and contributes to India having an estimated 11
million abortions per year. India’s ministry for Women and Child
development reportedly wants to introduce fines and even prison terms
for entire families who force a woman to abort a female fetus. And one
state, Uttar Pradesh has introduced baby hatches where people can leave
their unwanted baby girls.
Russia
Russia was the first country to legalise abortion in all circumstances
and has the highest rate of abortion worldwide—54/1000 women aged 15-44
(compared with 24/1000 in China). Over the decades the policy has been
changed, and recently it has been restricted by the government of Dmitri
Medvedev, which has close ties with the Orthodox church and is facing a
low birth rate and shrinking population. In October, parliament voted to
limit the period for abortion to 12 weeks of gestation and up to 22
weeks in the case of rape.9 There is no time limit if there is a risk to
the mother’s life. Abortion providers are now required to spend 10% of
advertising costs on warning of the possible dangers to a woman’s
health, and it is illegal to describe abortion as safe. The president’s
wife has taken a leading role in anti-abortion campaigns alongside
leaders of the Orthodox church.
United States
Abortion has always been a subject of heated debate across the US, but
in the past decade there has been a frenzied tightening of restrictions
in many states that were previously moderate. Overall, according to the
Guttmacher Institute, there were 92 new provisions restricting abortion
in 2011, compared with 34 in 2005.10 This year there have been at least
39 new restrictions. In 2000, around a third of American women of
reproductive age lived in states that were hostile to abortion rights, a
third in states that were supportive, and a third in states that stood
somewhere in between. By 2011, over half of American women lived in
states that were hostile. States found different ways to obstruct
women’s access to the procedure including insisting women must first
receive counselling against it, restricting public or private insurance
coverage, and making it difficult for physicians to obtain supplies of
mifepristone, the FDA approved treatment for medical abortions. Seven
largely rural states banned telemedicine for abortion in 2011, meaning a
doctor has to be with the patient when prescribing the treatment.
In 2010, Nebraska came up with a new argument for restricting the period
in which abortion is permitted. The state ruled to ban abortion after 20
weeks on the basis that the fetus can feel pain at that stage. This
theory is not backed up by established science,11 but seven other states
(Alabama, Idaho, Indiana, Kansas, Oklahoma, Georgia, and Louisiana)
followed with similar rulings. Arizona restricted abortions beyond 18
weeks in March this year using a similar argument.
Critics argue that these laws are unconstitutional because the landmark
1973 Supreme Court ruling in the case of Roe versus Wade held that
states could restrict or ban abortion only after fetal viability. It is
generally agreed that a fetus could survive outside the womb from 24
weeks at the earliest. Critics also argue that if the concern is for the
fetus not to experience pain it would suffice to use anaesthetics.
Latin America and Africa
In most of Latin America abortion is either totally banned (Nicaragua,
El Salvador) or tightly restricted. Across Africa colonial laws make it
legal in only a few situations—usually if a woman’s life is in danger or
in the case of fetal abnormality or rape or incest. Social and religious
disapproval also contributes to large numbers of women seeking
clandestine abortion, which often leads to complications and deaths. WHO
estimates that 5.5 million women in Africa have abortions every year,
99% of which are unsafe, and around 36 000 women die from the
procedure.12 In Ethiopia, for example, unsafe abortions are thought to
account for up to half of maternal deaths. Some 95% of abortions in
Latin America are also unsafe.12
In both regions, a few countries have recently decided to relax their
laws and make safe abortion services accessible on the basis that
criminalising it causes unnecessary deaths. In Kenya, the constitution
was changed in 2010 after years of debate over the need to relax the
laws and increase provision of safe abortions. Argentina legalised
abortion for raped women in March this year and Uruguay legalised
abortion up to 12 weeks in October and is providing government funded
abortion services. And since 2009, Ethiopia has piloted an apparently
successful programme in which trained health workers in one region
provide safe medical abortions with misoprostol.
Arab world
Unlike most Muslim countries, Tunisia legalised abortion in the 1970s.
The only conditions are that it must be carried out by a qualified
practitioner within the first three months of pregnancy. The country’s
leaders repressed the population in many ways before the Arab Spring of
2011 but they liberated women by encouraging all sorts of birth control
in a bid to control population growth. As a result, the country has the
lowest birth rate in the region—2.0 births/1000 women, according to the
World Bank’s latest figures.13 It remains to be seen whether the Arab
Spring will lead to a relaxing of laws across the Arab world, where
abortion is generally available only if a woman’s life is in danger.
Data are patchy but according to the International Planned Parenthood
Federation, in the five years up to 2000, there were 15 million unwanted
pregnancies across the Arab world and over seven million abortions in
the same period.14 Clandestine abortions seem to be common, and it is
estimated that 5% of maternal deaths are due to unsafe abortions.
Because of cultural disapproval, most campaign groups are focusing on
promoting better awareness and availability of contraception rather than
safe abortions.
Iran
Iran has a relatively low abortion rate compared with other countries,
probably because its well educated population makes better use of
contraception. But the country’s leaders have begun slashing family
planning services and appealing for bigger families in a bid to boost
the population. It’s not yet clear how much families are heeding the
call to procreate, but the changing government position is likely to
produce an increase in the numbers of abortions.
Competing interests: All authors have completed the unified
competing interest form at www.icmje.org/coi_disclosure.pdf (available
on request from the corresponding author) and declare no support from
any organisation for the submitted work; no financial relationships with
any organisation that might have an interest in the submitted work in
the previous three years; and no other relationships or activities that
could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.
References
- Northern Ireland Health Ministry. Statistics on terminations of pregnancy.
- Department of Health. Numbers travelling to UK for abortions from the Republic of Ireland and Northern Ireland. Table 12a.
- Smyth L. Abortion clinic may exploit and break the law, claims opponent. Belfast Telegraph 2012 Oct 18.
- Houston M. Ireland looks at ways to bring its abortion law into
line with European judgment. BMJ2012;345:e8165.
- China has more than 13 million abortions a year. CNN 2009 Jul 30.
- Guttmacher Institute. Facts on induced abortion worldwide.
- Chinese govt may seek end to late term forced abortions. LifeNews
2012 14 Sep.
- Jha P, Kesler MA, Kumar R, Ram F, Ram U, Aleksandrowicz L, et al.
Trends in selective abortions of girls in India: analysis of nationally
representative birth histories from 1990 to 2005 and census data from
1991 to 2011. Lancet2011;377:1921-8.
- Kishkovsky S. Russia enacts law opposing abortion. New York Times
2011 Jul 15.
- Benson Gold R, Nash E. Troubling trend: more states hostile to abortion rights as middle ground shrinks.
- Colghan A. 24-week fetuses cannot feel pain. New Scientist 2010 Jun
25.
- WHO. Unsafe abortions. 5th ed. 2005.
- World Bank. Fertility rate.
- International Planned Parenthood Federation. Abortion.