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50 MIllion Babies Killed Every Year!



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The Incidence of Abortion Worldwide

By Stanley K. Henshaw, Susheela Singh and Taylor Haas

Context: Accurate measurement of induced abortion levels has proven difficult in many parts of the world. Health care workers and policymakers need information on the incidence of both legal and illegal induced abortion to provide the needed services and to reduce the negative impact of unsafe abortion on women's health.

Methods: Numbers and rates of induced abortions were estimated from four sources: official statistics or other national data on legal abortions in 57 countries; estimates based on population surveys for two countries without official statistics; special studies for 10 countries where abortion is highly restricted; and worldwide and regional estimates of unsafe abortion from the World Health Organization.

Results: Approximately 26 million legal and 20 million illegal abortions were performed worldwide in 1995, resulting in a worldwide abortion rate of 35 per 1,000 women aged 15–44. Among the subregions of the world, Eastern Europe had the highest abortion rate (90 per 1,000) and Western Europe the lowest rate (11 per 1,000). Among countries where abortion is legal without restriction as to reason, the highest abortion rate, 83 per 1,000, was reported for Vietnam and the lowest, seven per 1,000, for Belgium and the Netherlands. Abortion rates are no lower overall in areas where abortion is generally restricted by law (and where many abortions are performed under unsafe conditions) than in areas where abortion is legally permitted.

Conclusions: Both developed and developing countries can have low abortion rates. Most countries, however, have moderate to high abortion rates, reflecting lower prevalence and effectiveness of contraceptive use. Stringent legal restrictions do not guarantee a low abortion rate.

By Stanley K. Henshaw, Susheela Singh and Taylor Haas

International Family Planning Perspectives, 1999, 25(Supplement):S30–S38 The Programme of Action of the 1994 International Conference on Population and Development urged governments and other relevant organizations "to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family-planning services."1 To implement this recommendation, policymakers need information on the availability and quality of family planning services, the extent of harm to women's health caused by unsafe abortion, and the incidence of abortion.

This article focuses on the last of these factors, the incidence of both legal and illegal abortions in each country or area. Comparative data provide insight into the levels of abortion that might be achievable for a particular country and into the factors that influence abortion rates.

Despite its importance, accurate measurement of the level of induced abortion has proven difficult to achieve in many parts of the world. In many countries where abortion is legal under broad conditions, statistics on abortion are collected and are of reasonable completeness and accuracy, but in others, official data are lacking or are incomplete. A common problem is that some privately performed procedures go unreported and are therefore not counted.

In addition, the availability of statistics is limited by other factors. In some countries, only certain categories of abortions may be reported--for example, only those that comply with official requirements and regulations, those performed in settings where reporting is routine (such as hospitals or clinics) or those paid for by government insurance. Moreover, in some areas where reporting is legally required, enforcement is uneven.

That no official statistics would be available in countries where abortion is highly restricted by law and can carry the possibility of severe consequences is understandable. In these settings, moreover, attempts to collect information on induced abortion by other methods (for example, by directly questioning women, doctors or other potential providers) are unlikely to elicit accurate reports.2

As a result of these problems, we have used a variety of data sources, data collection approaches and methods of estimation to obtain the best possible estimates of the number of induced abortions occurring worldwide and in specific regions and countries. The research reported on in this article continues a series of worldwide overviews of the level of abortion and takes a similar approach to data compilation and estimation.3 It also draws on compilations of the level of abortion from organizations and researchers for various regions or countries.4

This article presents current estimates of the level of induced abortion, based on a recent effort to assemble all available official statistics from countries that collect such data, as well as existing estimates of the level of induced abortion for countries that have no official statistics. We incorporate worldwide and regional estimates from the World Health Organization (WHO) of the number of unsafe abortions, which the organization defines as abortions that do not meet the legal requirements in countries where abortion is generally permitted as well as abortions in restrictive countries. (Thus, WHO's estimates of "unsafe" procedures can be considered estimates of illegal abortions.) We combine these estimates with all available data on legal abortions to arrive at estimates of the overall number and level of induced abortion, whether safe or unsafe, legal or illegal.

Methods and Data SourcesCountries with Nonrestrictive LawsOur aim was to obtain abortion statistics from all countries* where legal abortion was generally available in 1997 and that had populations of one million or more. In each country where we believed data would be available, we requested information and published reports containing abortion statistics from the national statistical office or a local informed expert. (The experts were government officials, scientists interested in abortion and family planning officials.) For most countries, we sent a questionnaire requesting specific abortion, birth and population data.

Abortion data are generally collected by government agencies, which compile statistics from health facilities and physicians that perform abortions. Although reporting is usually required, it is nevertheless incomplete--and thus potentially misleading--in many countries. Therefore, we asked the local experts for an assessment of the completeness of the data, and we have set apart results for countries where reporting is incomplete or of unknown completeness.

We obtained data from 50 of the 56 countries that allowed abortion on socioeconomic grounds or without restriction as to reason for the procedure in 1997.5 † We also have information for nine countries where laws are more restrictive but where legal abortion services are nevertheless available to many women.

For all but seven of these 59 countries, we present government abortion statistics. In Australia, we obtained data from records of national health insurance payments and hospital records.6 The number of abortions in Puerto Rico was projected from a survey of abortion providers,7 while household surveys were used for the Republic of Korea (South Korea) and Turkey.8 We took the number of abortions in Switzerland from a publication reporting the number in each canton, with estimates for two cantons.9 For the United States, we used data published by The Alan Guttmacher Institute (AGI) in preference to government statistics, which are incomplete for many states. (AGI statistics are derived from periodic surveys of all abortion providers.10) Data for Zambia came from one hospital where almost all legal abortions are performed.11

In some settings, multiple reporting systems give different statistics. Systems of classifying abortions may or may not include early abortions performed by vacuum aspiration (manual or electric), spontaneous abortions or criminal abortions, and some distinguish between elective and therapeutic abortions. In situations like these, we have relied on the advice of in-country experts to assess the reliability of data from each system and to inform our decision to combine sources or present data from only one source.

For example, in some former Soviet states, both the ministry of health and the federal statistical bureau compile abortion statistics, but both sets of statistics have shortcomings. For the Russian Federation, for example, we have used the Ministry of Health statistics, although they exclude abortions performed in the facilities of the Ministry of Transportation and other ministries. The statistical bureau collects data from all ministries but its abortion count includes spontaneous abortions and omits early vacuum aspiration abortions.

For China, we have also used Ministry of Health statistics, in part because they are available for more years. Although there have been suggestions that the administrative units that supply data to the Ministry of Health may have had a tendency to over- report in the past, we judge that the total count is probably too low, especially in recent years, because of the omission of approximately one million medical (mifepristone) abortions per year and incomplete reporting from family planning clinics. The family planning program also compiles abortion statistics, but these data are derived in part from self-reports at local meetings of women; they exclude unmarried women, they omit abortions in many city hospitals and provinces are missing for some years. Even so, for some years the family planning totals are higher than those of the Ministry of Health.

For South Korea and Turkey, two countries with no national registration or service statistics, we present estimates from surveys that asked ever-married women aged 20–44 (South Korea) or 15–49 (Turkey) about their abortion experience in the previous year. The number of abortions for each of these countries is underestimated because abortions to unmarried women are not included. Given South Korea's very high mean age at marriage (about 26–27 for women), the proportion of women who are unmarried is substantial, and a significant number of abortions are being obtained by unmarried women.12

The median age at first marriage in Turkey is lower (19), and although premarital sexual activity is not believed to be common, some abortions are probably occurring among unmarried women. In addition, underreporting of abortions is common in surveys. However, reporting appears to be relatively complete in countries such as South Korea and Turkey, where abortion is legal and less stigmatized, and where reported levels are high.

For our regional and worldwide estimates of the number of legal abortions, we needed to include uncounted legal abortions for countries where abortion reporting is incomplete or nonexistent. For France and Italy, we used estimates made by local experts.13 For the remaining countries, we took into account the opinions of local experts, as well as abortion rates in countries with a similar profile of abortion service provision and similar legal and social conditions regarding abortion. Seventy-one percent of our estimated number of legal abortions worldwide were reported and 29% were estimates of uncounted abortions.

For population estimates and numbers of live births needed to calculate rates and ratios, where possible we used data from official sources that were either published, obtained from country statistical offices or provided by our in-country experts. Data compilations published by the Council of Europe and the United Nations (UN) were used if data were unobtainable or if gaps existed in available official data.14 For some countries, we used birth estimates provided by the Population Reference Bureau. For countries for which we could not obtain official estimates of the population of women aged 15–44, we relied on the estimates of the UN Population Division15 and interpolated where necessary.

Countries with Highly Restrictive LawsOfficial statistics on illegal abortions are usually not available for countries with restrictive laws. For regional and worldwide estimates, we used WHO's estimates of the number of abortions occurring in areas where abortion is highly restricted, and of the number of unsafe abortions occurring in areas where abortion is legally permitted but where significant numbers are performed under illegal conditions.16 These estimates are based on "indirect" techniques and take into account a variety of existing information on abortion, including studies reporting the ratio of births to abortion complications treated in hospitals, information on access to clandestine abortion services from trained physicians, the likelihood that women having abortions will experience complications, the degree of access to hospital treatment and the level of urbanization.

These techniques use information obtained from a number of sources: official statistics on women hospitalized for the treatment of abortion complications; hospital studies; surveys of medical facilities; and surveys of providers, women or abortion patients. Each of these sources suffers from some inadequacy, and adjustments and assumptions are necessary to allow for these data limitations.

Where abortion is highly restricted, data-based abortion estimates are scarce because they require extensive research. Such estimates start with statistics on the number of women hospitalized for abortion complications and build on these data, correcting for undercoverage and underreporting, and then obtain the number of induced abortions by removing spontaneous abortions. In the existing literature, we located estimates for 10 countries for a recent time period.17 This group of countries includes Bangladesh, where menstrual regulation is permitted and reported in official statistics, but abortions are legally restricted, although common.

An important step is to determine the proportion of all women having a clandestine abortion who are likely to be hospitalized for complications; this factor is estimated based on findings from available community surveys and from opinion surveys of health professionals. However, because two key elements--access to safe abortion procedures and access to hospital care--are both subject to change, the estimates take this into account as far as possible by using any available information on access to safe abortion services or to hospital care, by comparing different sources over time and by using the most recent source.

The estimates for two of these 10 countries included an additional component. For Nigeria, an estimate of the number of abortions provided by private doctors, obtained by surveying a sample of medical facilities, is also incorporated.18 For Bangladesh, the number includes an estimate of menstrual regulation procedures calculated from official statistics adjusted on the basis of survey results for the level of under-reporting of such procedures by providers.19

Worldwide and Regional EstimatesThe estimated number of legal and illegal abortions and their sum, the estimated total number of abortions worldwide, all have a margin of error of a few million. Much of the possible error in the worldwide number of legal abortions comes from the need to estimate the level of under-reporting in four large areas--China, India, Japan and the former Soviet bloc states. The numbers of abortions in these areas are large and influence the total estimate, and our assumptions about the level of completeness contribute to the margin of error around the world estimate. For the total number of illegal abortions worldwide, the WHO estimates involve a fair degree of uncertainty, given the indirect estimation methodology that was used.

FindingsGlobal IncidenceApproximately 46 million abortions were performed worldwide in 1995 (Table 1). Of these, about 26 million were legal and 20 million illegal.‡ The abortion rate worldwide was about 35 per 1,000 women aged 15–44. Of all pregnancies (excluding miscarriages and stillbirths), 26% were terminated by abortion.§ Table 1. Estimated number of induced abortions, by legal status, percentage of all abortions that are illegal, abortion rate and abortion ratio, all according to region and subregion, 1995 Region and subregion No. of abortions (millions) % illegal Rate* Ratio† The Number of - Total Legal Illegal %Illegal Abortions No. of 45.5 25.6 19.9

Africa (all of)- 05.0 00.1 04.9 - 99%

Asia (all of) - 26.8 16.9 09.9 - 37%

America North - 01.5 01.4 00.1 - .1%

America Latin - 04.2 00.2 04.0 - 95%

America South - 03.0 00.0 2.99 - 99%

Australia-N Zeal 01.1 00.9 00.2 - 20%

Europe (all of)- 07.7 06.8 00.9 - 12%

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