Contribution of anti-abortion laws to maternal mortality in developing countries

Unsafe abortion is a critical public health problem and an important cause of maternal mortality in developing countries. Of the estimated 600,000 maternal deaths that occur worldwide each year, 13% are attributable to complications of induced and unsafe abortion [1]. Many of these deaths, especially those due to unsafe abortion, occur in developing countries, while only low numbers occur in developed countries. The WHO estimates that 67,800 women die from abortion complications each year [2]; 67,500 women die in developing countries, while only 300 of these deaths occur in developed countries. The data suggest a ratio of 330 abortion-related deaths per 100,000 abortions in developing countries, compared with a ratio of only 0.7 per 100,000 abortions in developed countries [3]. Africa has the highest mortality ratio of 680 per 100,000 abortions, followed by South and Southeast Asia with a ratio of 283 per 100,000 abortions and Latin America with a ratio of 119 per 100,000 abortions [3]. The risk of dying from unsafe abortion is highest in Africa, with a rate of one in 150, compared with rates of one in 250 in Asia, one in 900 in Latin America and the Caribbean, and one in 1900 in Europe.

Several factors account for the high rate of mortality associated with induced abortion in developing countries. These include adverse socioeconomic, cultural and religious factors, which limit women’s access to family planning services for the prevention of unwanted pregnancies, and unfavorable service delivery systems, which restrict access to postabortion care for women suffering complications of unsafe and induced abortion. However, restrictive abortion laws in developing countries have had the most profound effect on abortion mortality, as they prevent women from seeking evidence-based care for termination of unwanted pregnancies. Contrary to the intentions of protagonists, restrictive antiabortion laws have not been known to reduce the rate of abortion in any setting. By contrast, such laws often drive women to resort to harmful and dangerous methods of abortion, with resulting severe complications and death.

To date, it is well known that 61% of the world’s population lives in countries where induced abortion is allowed for a wide range of reasons, such as protection of the woman’s life, preservation of her mental and physical health and for broad socioeconomic reasons [101]. By contrast, 26% of the world lives in the 72 mostly developing countries where abortion is totally prohibited or allowed only to save the woman’s life. Most restrictive laws in developing countries emanated from their European colonizers. However, while these European nations have discarded their restrictive laws, many formerly colonized developing countries have held tenaciously to the restrictive laws.

The impact of antiabortion law on maternal mortality is most illustrated by data showing the prevalence of unsafe abortion and abortion mortality in countries with restrictive abortion laws compared with those with liberal abortion laws. The prevalence of unsafe abortion is highest in countries with the most restrictive laws, up to 23 unsafe abortions per 1000 women of reproductive age [4], while countries that allow abortion on request have a median unsafe abortion rate of two or less per 1000 women. Case–fatality rate from unsafe abortions is also highest in countries where abortion is legally restricted. In such countries, the median ratio for unsafe abortion mortality is 34 deaths per 100,000 live births, compared with one or less per 100,000 livebirths in countries that allow abortion on request.

Romania and South Africa are two countries that best demonstrate the effects of liberal abortion laws on maternal mortality. Maternal mortality due to abortion increased in Romania after a restrictive abortion policy was introduced in 1966. By 1989, mortality ratios had risen sevenfold to peak at 148 deaths per 100,000 livebirths, with abortion accounting for 87% of the deaths [5]. When the policy was reversed in 1989, mortality ratio fell by more than half to 68 within 1 year, and by 2002 the ratio had fallen to as low as nine per 100,000 live births, with abortion accounting for less than 50% of the deaths. Similarly, abortion became legal and available on request in South Africa in 1997 [102]. After the law was passed, abortion-related deaths dropped by 91% in South Africa between 1994 and 2001 [8].

Clearly, liberalization of abortion laws is an important strategy to reduce mortality due to unsafe abortion. In the last 12 years, 12 developing countries have liberalized their abortion laws. These include Albania, Benin, Burkina Faso, Cambodia, Chad, Ethiopia, Ghana, Guinea, Guyana, Mali, Nepal and South Africa. Although the effects of these laws on mortality have not been systematically quantified in all these countries, for countries where accurate data are available, abortion liberalization has been shown to result in a substantial decline in maternal mortality.

With the known positive effect of abortion liberalization in reducing maternal mortality, it is surprising that many developing countries are still holding on to restrictive antiabortion laws. Two types of arguments are often put forward by those opposed to abortion liberalization in developing countries. The first is that liberalization will increase the rate of abortion and overburden the healthcare infrastructure. However, experiences in countries that liberalized their abortion laws such as Barbados, Canada, South Africa, Tunisia and Turkey indicate that abortion liberalization has not been associated with increase in abortion [3]. By contrast, The Netherlands, which has unrestricted access to free abortion and contraception, has one of the lowest abortion rates in the world [3].

The second argument, especially for low resource countries, is that women will still not seek safe abortion services even when abortion is liberalized. The examples of India, Zambia and Ghana where women continue to experience poor access to safe abortion care despite liberal abortion laws are often cited to support this viewpoint [1,7]. Factors associated with poor access in such circumstances include women’s and providers’ inadequate knowledge of the revised law, continued stigmatization of abortion and sexuality due to sociocultural and religious reasons, and weak health systems in some of the developing countries [8,9]. Addressing these problems as part of abortion law reform, in addition to advocacy and public-health education would increase the benefits of liberalization in reducing mortality associated with unsafe abortion.

In conclusion, restrictive antiabortion laws that drive abortion underground make it unsafe, and contribute to the high maternal mortality associated with unsafe abortion in developing countries. Women in developing countries will always have abortion irrespective of prevailing laws and social prescriptions. It is clear and incontrovertible that increasing access to safe abortion by removing legal barriers to abortion can improve the health of women in developing countries. The recommendations from several international conferences over the past decade all agree on the need for countries to invest in abortion safety and availability as one way to save the lives of thousands of women each year. Developing countries have a moral, social and ethical responsibility to implement these recommendations in order to reduce unnecessary deaths and promote the health and social wellbeing of women.

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.