Elsevier

The Lancet

Volume 379, Issue 9816, 18–24 February 2012, Pages 625-632
The Lancet

Articles
Induced abortion: incidence and trends worldwide from 1995 to 2008

https://doi.org/10.1016/S0140-6736(11)61786-8Get rights and content

Summary

Background

Data of abortion incidence and trends are needed to monitor progress toward improvement of maternal health and access to family planning. To date, estimates of safe and unsafe abortion worldwide have only been made for 1995 and 2003.

Methods

We used the standard WHO definition of unsafe abortions. Safe abortion estimates were based largely on official statistics and nationally representative surveys. Unsafe abortion estimates were based primarily on information from published studies, hospital records, and surveys of women. We used additional sources and systematic approaches to make corrections and projections as needed where data were misreported, incomplete, or from earlier years. We assessed trends in abortion incidence using rates developed for 1995, 2003, and 2008 with the same methodology. We used linear regression models to explore the association of the legal status of abortion with the abortion rate across subregions of the world in 2008.

Findings

The global abortion rate was stable between 2003 and 2008, with rates of 29 and 28 abortions per 1000 women aged 15–44 years, respectively, following a period of decline from 35 abortions per 1000 women in 1995. The average annual percent change in the rate was nearly 2·4% between 1995 and 2003 and 0·3% between 2003 and 2008. Worldwide, 49% of abortions were unsafe in 2008, compared to 44% in 1995. About one in five pregnancies ended in abortion in 2008. The abortion rate was lower in subregions where more women live under liberal abortion laws (p<0·05).

Interpretation

The substantial decline in the abortion rate observed earlier has stalled, and the proportion of all abortions that are unsafe has increased. Restrictive abortion laws are not associated with lower abortion rates. Measures to reduce the incidence of unintended pregnancy and unsafe abortion, including investments in family planning services and safe abortion care, are crucial steps toward achieving the Millennium Development Goals.

Funding

UK Department for International Development, Dutch Ministry of Foreign Affairs, and John D and Catherine T MacArthur Foundation.

Introduction

Information on global and regional abortion rates and trends can help identify gaps in contraceptive use. Although abortions done according to medical guidelines carry very low risk of complications,1, 2, 3 unsafe abortions contribute substantially to maternal morbidity and death worldwide.4, 5, 6 Monitoring abortion trends is thus crucial to assess improvement of maternal health, and the progress toward the UN Millennium Development Goal 5 (MDG 5), to reduce maternal mortality and achieve universal access to reproductive health.

Moreover, one of the many controversies surrounding abortion is whether restrictive abortion laws prevent women from obtaining abortions. Analyses of the association between abortion incidence and the legal status of abortion can clarify whether law is a factor that affects abortion incidence.

However, abortions are not documented in countries with highly restrictive abortion laws and are often under-reported elsewhere, especially where the practice is highly stigmatised. Therefore, estimation of regional and global incidence requires compilation of information from a range of sources and careful assessment of information for quality and completeness. Various data sources and estimation approaches have been assessed, refined, and applied over the years, and are now widely accepted as sources of reasonable national estimates.4, 7, 8, 9

We estimated the incidence of safe and unsafe abortion globally and in all the major regions and subregions of the world in 2008. We assessed trends since 1995 and 2003, the only other years for which similar assessments were done. We also examined the associations of abortion incidence with the legal status of abortion across the world's subregions.

Section snippets

Definitions and data sources

We adhered to the definition of unsafe abortion established by WHO, namely, a procedure for termination of an unintended pregnancy done either by people lacking the necessary skills or in an environment that does not conform to minimum medical standards, or both.10 As elaborated by WHO,4, 11 abortions done outside the bounds of law are likely to be unsafe even if they are done by people with medical training for several reasons: such procedures are usually done outside facilities authorised to

Results

An estimated 43·8 million abortions occurred in 2008, compared with 41·6 million in 2003, and 45·6 in 1995 (table 1). About 78% of all abortions took place in the developing world in 1995, and increased to 86% in 2008, whereas the proportion of all women of reproductive age who live in the developing world rose from 80% to 84% in the same interval. Since 2003, the number of abortions fell by 0·6 million in the developed world, but increased by 2·8 million in developing countries. The estimated

Discussion

Our findings show that the substantial decline in the abortion rate observed between 1995 and 2003 has tapered off, and the proportion of abortions that are unsafe has increased since 1995, such that nearly half of all abortions worldwide were unsafe in 2008.

Our estimates of the rates of unsafe abortion across countries and regions tend to align with independent subnational, national, and regional research of the incidence of abortion-related morbidity and mortality, where such evidence exists.

References (50)

  • G Sedgh et al.

    Legal abortion worldwide in 2008: levels and recent trends

    Int Perspect Sex Reprod Health

    (2011)
  • C Rossier

    Estimating induced abortion rates: a review

    Stud Fam Plann

    (2003)
  • The prevention and management of unsafe abortion. Report of a technical working group

    (1992)
  • S Singh et al.

    Abortion worldwide: a decade of uneven progress

    (2009)
  • R Duggal et al.

    Summary and key findings, abortion assessment project-India

    (2004)
  • Fetters T, Samandari G. An estimate of safe and unsafely induced abortion in Cambodia. Paper presented at the XXVI...
  • J Harries et al.

    Health care providers' attitudes towards termination of pregnancy: a qualitative study in South Africa. BMC Public Health, 2009, Vol. 9, Art. 296

  • Reproductive, maternal and child health in Eastern Europe and Eurasia: a comparative report (revised 2005)

    (2003)
  • RK Jones

    How commonly do US abortion patients report attempts to self-induce?

    Am J Obstet Gynecol

    (2011)
  • G Sedgh et al.

    Measuring the incidence of abortion in countries with liberal laws

  • EF Jones et al.

    Underreporting of abortion in surveys of US women: 1976 to 1988

    Demography

    (1992)
  • RK Jones et al.

    Underreporting of induced and spontaneous abortion in the United States: an analysis of the 2002 National Survey of Family Growth

    Stud Fam Plann

    (2007)
  • S Singh et al.

    The abortion incidence complications method: a quantitative technique

  • S Singh et al.

    The estimated incidence of induced abortion in Ethiopia, 2008

    Int Perspect Sex Reprod Health

    (2010)
  • Cited by (472)

    View all citing articles on Scopus
    View full text