In countries where abortion is illegal, are there fewer abortions?
The question sounds simple. But it's tough to answer, says social demographer Jonathan Bearak at the Guttmacher Institute. That's largely because, in places with strict abortion laws, the procedure is almost completely hidden. So estimating the rate of abortions is extremely difficult.
Nevertheless, for the past two decades scientists at the World Health Organization and the Guttmacher Institute have been developing tools to estimate abortion rates around the globe. Both institutions support abortion rights for people worldwide. This past February, they published, for the first time, abortion rates for nearly every country. And they've also updated their analysis looking at how abortion rates vary across regions of the world – and whether the legality of the procedure is associated with those rates.
"So let's say you group together the countries where abortion is broadly legal," says Bearak, who led the study. "And then you group together countries where abortion is completely prohibited altogether, even without exception for the health of the woman."
Which group has the higher abortion rate?
Here's what they found. In countries where abortion is broadly legal, there are between 36 and 47 abortions performed annually per 1,000 women, ages 15 to 49. And what about in countries where abortions are prohibited altogether? "In these countries, there are between 31 and 51 abortions annually per 1,000 women, on average," Bearak says.
"People can be surprised by the findings," he says, "because the rates are basically the same across the two groups of countries."
How could that be?
In countries where abortion is broadly legal, use of contraception is quite high, Bearak and his team found. That's because these countries tend to be richer and have strong health-care systems. "If you have a stronger health-care system and provide universal access to sexual reproductive health care, you would expect a lower unintended pregnancy rate," Bearak says. And so the rate of unintended pregnancies tends to be low (between 53 to 66 unintended pregnancies annually per 1,000 women, ages 15 to 49). But the percentage of those pregnancies ending in abortion is higher because abortions tend to accessible.
By contrast, in countries where abortions are heavily restricted, use of contraception tends to be low, his team found. And thus, the rate of unintended pregnancies is high (between 70 to 91 unintended pregnancies annually per 1,000 women, ages 15 to 49). But the percentage of those pregnancies ending in an abortion is low, likely because abortions aren't easily accessible.
So, Bearak says, in the end, highly restrictive abortion laws don't correlate with a lower abortion rate. Instead, those laws correlate with more unintended pregnancies, which ultimately leads to an abortion rate comparable to what's observed in countries where the procedure is accessible.
"Many studies have shown that making abortions illegal doesn't decline the number of abortions," Ana Langer, at Harvard T. H. Chan School of Public Health, told NPR. "Once a procedure becomes illegal, the need is still there. Women will look for services, safe or unsafe, to terminate their pregnancy."
Now there are many caveats to the new study. For starters, in some countries, health officials collect very little data on abortion procedures. So Bearak and his team had to estimate abortion rates and unintended pregnancies from a computer model. They built that model based on survey data collected through a United Nations initiative that tracks "contraceptive prevalence and the unmet need for family planning" around the world.
"These are major global health surveys performed at regular intervals," Bearak says, "in which women are asked, 'Okay, you had a birth. Was this unintended?'" His team then combined this data with known abortion statistics to generate a computer model that could estimate unintended pregnancies and abortion rates where data were insufficient. "Because these estimates are based on models, they come with uncertainty," he explains.
On top of that, Bearak says, their estimates can't assess how changing abortion laws in a country would or wouldn't alter the rates in the short-term. For example, in the U.S. some states, including Texas, are currently tightening abortion laws.
"So we can certainly see early evidence in Texas that people are having trouble accessing abortions, which makes intuitive sense," Bearak says. And so the restrictions in Texas will likely lead to lower rates of abortion in the short-term. "But exactly how that's going to play out in the long run is yet to be seen. We don't know how people will adapt."
A major way that women "adapt" is to seek abortion in nearby places, where the procedure is legal, or to seek illegal abortions, says Fatima Juárez, who's a demographer at El Colegio de México in Mexico City. Juárez's research focuses on the reproductive health of young people.
In places where abortions are illegal, she says, it can be difficult to obtain a safe abortion – that is, an abortion where the risk of severe complications is extremely low.
In a study published in 2019, Juárez and her colleagues interviewed women across Mexico about their experiences having abortions. The team focused on three states with varying levels of restriction, from few restrictions in Mexico state to many restrictions in Queretaro state.
"What we found was that in states where abortion is illegal, it's very difficult for a woman to control the outcome of the abortion. There's this element of chance," Juárez says – a chance that the abortion could end up unsafe.
So while the overall rate of abortion doesn't correlate well with the legality of the procedure, the rate of unsafe abortions shows a strong relationship with local abortion laws, says Dr. Bela Ganatra, who leads the Prevention of Unsafe Abortion Unit at the World Health Organization.
"We found that in countries where abortion is legal – and available to women on request – 9 out of 10 abortions happen safely," Ganatra says. "But if you look at countries where abortions are most restricted then only 1 out of 4 abortions happens safely."
"But it's not just the law that's important," she adds. For the rate of unsafe abortions to drop in a country, people also have to have access to safe abortions, she says. "Just because the law changes and abortion is allowed, it doesn't automatically mean that unsafe abortion goes away. Clinics actually have to have the medicines, they have to train practitioners and they actually have to make the services available.
"Changing the law [to allow abortions] is necessary for reducing the rate of unsafe abortions. It's a step, but it's not only about the law," Ganatra adds.