Global Developments in Laws on Induced Abortion: 2008-2019.

CONTEXT: Evidence shows that laws that restrict abortion do not eliminate its practice, but instead result in women having clandestine abortions, which are likely to be unsafe. It is important to periodically assess changes in the legal status of abortion around the world. METHODS: The criteria for legal abortion as of 2019 for 199 countries and territories were used to distribute them along a continuum of six mutually exclusive categories, from prohibited to permitted without restriction as to reason. The three most common additional legal grounds that fall outside of this continuum-rape, incest and fetal anomaly-were also quantified. Patterns by region and per capita gross national income were examined. Changes resulting from law reform and judicial decisions since 2008 were assessed, as were changes in policies and guidelines that affect access. RESULTS: Legality correlated positively with income: The proportions of countries in the two most-liberal categories rose uniformly with gross national income. From 2008 to 2019,27 countries expanded the number of legal grounds for abortion; of those, 21 advanced to another legality category, and six added at least one of the most common additional legal grounds. Reform resulted from a range of strategies, generally involving multiple stakeholders and calls for compliance with international human rights norms. CONCLUSIONS: The global trend toward liberalization continued over the past decade; however, even greater progress is needed to guarantee all women's right to legal abortion and to ensure adequate access to safe services in all countries.

RESUMEN Contexto: La evidencia muestra que las leyes que restringen el aborto no eliminan su práctica, sino que dan como resultado que las mujeres se sometan a abortos clandestinos, que probablemente no sean seguros. Es importante evaluar periódicamente los cambios en la situación legal del aborto en todo el mundo. Métodos: Se utilizaron los criterios que definen el aborto legal aplicados en 199 países y territorios a partir de 2019 para distribuirlos a lo largo de un continuo de seis categorías mutuamente excluyentes, desde prohibido totalmente hasta permitido sin restricción en cuanto a razón. También se cuantificaron las tres causales legales adicionales más comunes que caen fuera de este continuo: violación, incesto y anomalía fetal. Se examinaron los patrones por región y el ingreso nacional bruto per cápita. Se evaluaron los cambios resultantes de la reforma legal y las decisiones judiciales a partir de 2008, así como los cambios en las políticas y lineamientos que afectan el acceso a los servicios. Resultados: La legalidad se correlacionó positivamente con el ingreso: las proporciones de países en las dos categorías más liberales aumentaron uniformemente con el INB. De 2008 a 2019, 27 países ampliaron el número de causales legales para el aborto; de ellos, 21 avanzaron a otra categoría de legalidad y seis agregaron al menos una de las causales legales adicionales más comunes. La reforma fue el resultado de una variedad de estrategias, que generalmente involucran a múltiples partes interesadas y exigen el cumplimiento de las normas internacionales de derechos humanos. Conclusiones: La tendencia mundial hacia la liberalización continuó durante la última década; sin embargo, se necesitan avances aún mayores para garantizar el derecho de todas las mujeres al aborto legal y para asegurar un acceso adecuado a servicios seguros en todos los países.

RÉSUMÉ Contexte: Les données montrent que les lois restrictives de l'avortement n'éliminent pas sa pratique, mais qu'elles conduisent plutôt les femmes à l'avortement clandestin, souvent non médicalisé. Il importe d'évaluer régulièrement l'évolution de la légalité de l'avortement dans le monde. Méthodes: Les critères de l'avortement légal en 2019 concernant 199 pays et territoires ont servi de base à leur répartition le long d'un continuum de six catégories mutuellement exclusives, de l'interdiction absolue à l'autorisation sans restriction de motivation. Les trois raisons légales supplémentaires les plus courantes en dehors de ce continuum ­ le viol, l'inceste et la malformation fœtale ­ ont aussi été quantifées. Les tendances par région et en fonction du revenu national brut par habitant ont été examinées. Les changements survenus du fait de la réforme légale et de décisions judiciaires depuis 2008 ont été évalués, de même que l'évolution des politiques et des directives qui affectent l'accès. Résultats: La légalité présente une corrélation positive avec le revenu: les proportions de pays compris dans les deux catégories les plus libérales augmentent uniformément avec le RNB. De 2008 à 2019, 27 pays ont accru le nombre de raisons d'admission légale de l'avortement. Parmi eux, 21 ont progressé vers une autre catégorie de légalité, tandis que six ajoutaient au moins une des raisons supplémentaires les plus courantes. La réforme est le produit de diverses stratégies, impliquant généralement plusieurs intervenants et l'appel au respect des normes internationales en matière de droits humains. Conclusions: La tendance mondiale à la libéralisation s'est poursuivie ces 10 dernières années. Plus de progrès encore sont cependant nécessaires pour garantir le droit de toutes les femmes à l'avortement légal et assurer un accès adéquat à des services sécurisés dans tous les pays.

Sexual and Reproductive Health Needs of Adolescents in Zimbabwe.

(1) As of 2011, 38% of young Zimbabwean women have had sex by age 18, as have 23% of young men; this difference has widened over time. Females now first have sex nearly two years sooner than males. (2) One-quarter of 15-19-year-old women have started childbearing; one-third of all births to adolescents are unplanned (wanted later or not at all). (3) Favorable trends of rising modern contraceptive use in urban areas were likely interrupted by the worst of the economic crisis in 2008. Use among married adolescents declined in urban areas (from 50% in 2006 to 29% in 2011), even as it rose in rural areas (from 30% to 37%). (4) Patterns in unmet need for contraception followed suit: In urban areas, the proportion of married adolescents who wanted to postpone childbearing but were not using a method rose between 2006 and 2011(from 14% to 28%); among their counterparts in rural areas, unmet need fell from 20% to 15% over this period. (5) Single, sexually active adolescents have by far the greatest unmet need--62% as of 2011, compared with 19% among their married counterparts. (6) Existing policies need clarification to assure that no adolescent is illegally denied services because of age. Youth-friendly sexual and reproductive health programs should be prioritized so today's HIV-positive adolescents, many of whom have been infected since birth, do not transmit the virus to yet another generation.

Menstrual regulation, unsafe abortion, and maternal health in Bangladesh.

Maternal mortality has declined considerably in Bangladesh over the past few decades. Some of that decline--though precisely how much cannot be quantified--is likely attributable to the country's menstrual regulation program,which allows women to establish nonpregnancy safely after a missed period and thus avoid recourse to unsafe abortion. Key Points. (1) Unsafe clandestine abortion persists in Bangladesh. In 2010, some 231,000 led to complications that were treated at health facilities, but another 341,000 cases were not. In all, 572,000 unsafe procedures led to complications that year. (2) Recourse to unsafe abortion can be avoided by use of the safe, government sanctioned service of menstrual regulation (MR)--establishing nonpregnancy after a missed period, most often using manual vacuum aspiration. In 2010, an estimated 653,000 women obtained MRs, a rate of 18 per 1,000 women of reproductive age. (3) The rate at which MRs result in complications that are treated in facilities is one-third that of the complications of induced abortions--120 per 1,000 MRs vs. 357 per 1,000 induced abortions. (4) There is room for improvement in MR service provision, however. In 2010, 43% of the facilities that could potentially offer it did not. Moreover, one-third of rural primary health care facilities did not provide the service. These are staffed by Family Welfare Visitors, recognized to be the backbone of the MR program. In addition, one-quarter of all MR clients were denied the procedure. (5) To assure that trends toward lower abortion-related morbidity and mortality continue, women need expanded access to the means of averting unsafe abortion. To that end, the government needs to address barriers to widespread, safe MR services, including women's limited knowledge of their availability, the reasons why facilities do not provide MRs or reject women who seek one, and the often poor quality of care.

Benefits of meeting women's contraceptive needs in Burkina Faso.

Many women and couples in Burkina Faso do not have the knowledge, means or support they need to protect their reproductive health and to have the number of children they desire. Consequently, many women have more children than they want or can care for. Others turn to induced abortion, which is overwhelmingly clandestine and potentially unsafe. By helping women and couples plan their families and have healthy babies, good reproductive health care--including sufficient access to contraceptive services--contributes directly to attaining three Millennium Development Goals (MDGs): reducing child mortality, improving maternal health, and combating HIV/AIDS. Improving contraceptive services may also make meeting other MDGs--such as achieving universal primary education, reducing endemic poverty and promoting women's empowerment and equality--easier and more affordable. This In Brief aims to chart a course toward better health for Burkinabe women and their families by highlighting the health benefits and cost savings that would result from improved contraceptive services. Building on prior work and using national data to provide estimates for 2009 (see box), it describes current patterns of contraceptive use and two hypothetical scenarios of increased use to quantify the net benefits to women and society that would result from helping women avoid pregnancies they do not want. We focus on the disability and deaths that would be averted and the financial resources that would be saved through preventing unintended pregnancy.

Benefits of meeting the contraceptive needs of Ethiopian women.

The ability to practice contraception is essential to protecting Ethiopian women's health and enables them to plan the size and timing of their families. Yet low levels of contraceptive use have led to high levels of unintended pregnancy in Ethiopia, a problem for which women and society pay dearly-in women's lives, family well-being and public funds.

Benefits of meeting the contraceptive needs of Ugandan women.

This brief describes current patterns of contraceptive use in Uganda and documents the high costs associated with persistently high unmet need for modern contraceptives. Building on prior work and using national data sets to project estimates for 2008, we outline the net benefits to women and society of averting unintended pregnancies with current levels of use and under two scenarios of increased investment in modern contraception. Although enabling women to meet their childbearing preferences leads to an array of benefits--such as enhancing women's ability to go to school, enter the workforce and participate politically--we focus exclusively on the health and monetary savings from averting unintended pregnancy.

Improving contraceptive use in the United States.

The average American woman--who wants two children--spends about three decades trying to avoid pregnancy and only a few years trying to become or being pregnant. Sexually active women who are not seeking pregnancy may nonetheless practice contraception poorly or may not use a method at all. A wide range of reasons explain this seeming contradiction, including personal feelings and beliefs; experiences with methods; fears about side effects; partner influences; cultural values and norms; and problems in the contraceptive care system. Helping women prevent unintended pregnancy requires a broad-based approach that addresses many of these issues. To identify possible strategies for improving contraceptive use in the United States, two nationally representative surveys investigated women's contraceptive experiences and clinicians' delivery of relevant care. One survey asked sexually active women aged 18-44 who were not seeking pregnancy about their contraceptive use patterns over a one-year period. We focused on adults because many studies have examined adolescents' behavior, and relatively little is known about the contraceptive difficulties experienced by adult women--who account for more than 90% of unintended pregnancies. The second survey asked public and private contraceptive service providers to describe their service delivery protocols and their perceptions of clients' difficulties with method use. Results of these surveys reveal a complex picture of women's motivation and of client-provider interactions that sometimes hinder effective contraceptive use. They also suggest a number of measures that providers can take to help clients improve their contraceptive practice--many of which would require only simple changes in counseling practices and clinical protocols--and that policymakers, researchers and advocates can take to help in this effort.

Early childbearing in Honduras: a continuing challenge.

(1) Honduras has the highest adolescent birthrate in Central America, at 137 births for every 1,000 15-19-year-olds. This rate has remained unchanged over the past two decades, despite declines in the birthrate among women in all other age-groups. In absolute numbers, births to adolescents increased by 50% between 1987 and 2001. (2) As of 2001, only one-third of all women aged 20-24 (and only one-seventh of those in rural areas) had completed primary school; less education is associated with a higher likelihood of early childbearing. (3) One-half of 20-24-year-olds give birth by age 20; this proportion is higher among the least-educated women (70%), the poorest women (64%) and those in rural areas (60%). (4) In 2001, 40% of all recent adolescent births were unplanned, and the highest proportion was among those with the most education (48%). Most sexually active 15-19-year-olds (70%) do not want to have a child in the next two years. (5) Despite these reproductive preferences, just one in three sexually active adolescents uses a modern contraceptive method. Overall, 48% of adolescents have an unmet need for effective contraception. (6) High levels of early childbearing coexist with low rates of professional prenatal and delivery care. In 2001, one-third of recent 15-24-year-old mothers did not make a single prenatal care visit. The same proportion gave birth without a medical professional in attendance. (7) Policies and programs that aim to promote adolescents' reproductive health and support their childbearing preferences exist, but they are often not fully implemented and need more official commitment and resources.

Early childbearing in Guatemala: a continuing challenge.

(1) Guatemala has the third highest adolescent birthrate in Central America-114 births for every 1,000 women aged 15-19 each year. (2) Only two-fifths of 20-24-year-old women have completed primary school. The proportion is one in four in rural areas and one in 10 among indigenous women. (3) One-half of young women enter into a union (formal or consensual) before their 20th birthday. Three-quarters of those with no schooling do so, compared with one-quarter of those with a primary education or more. (4) Forty-four percent of 20-24-year-olds were mothers by age 20; the proportion is highest among young women with no education (68%) and among indigenous women (54%). (5) The great majority of 15-19-year-old women in union-83%, with little variation by residence or ethnicity-do not want to have a child in the next two years. However, only 18% are using an effective contraceptive. (6) Although 70% of 15-24-year-olds who recently gave birth made at least one prenatal care visit, roughly half of the least educated and of indigenous women made none. Moreover, only half of 15-24-year-old mothers had professional medical care at their most recent delivery; the proportion is even lower among the least educated and indigenous women (one-quarter).

Early childbearing in Nicaragua: a continuing challenge.

(1) Among Nicaraguan women 20-24 years old, six in 10 had entered a union and almost half had had a child before their 20th birthday. (2) A quarter of all births in Nicaragua--35,000 per year--are to 15-19-year-olds. (3) Rural women, who have less education, on average, than their urban counterparts, are more likely than city dwellers to enter a union and become mothers during adolescence. (4) The proportion of 20-24-year-olds who had a child during adolescence is more than twice as high among the poorest as among those in the highest socioeconomic category. (5) Nearly half--45%--of births to adolescent women are unplanned, a level that varies little by women's urban-rural residence and their educational achievement. (6) Among all sexually active women aged 15-19 (in union and not in union), 86% do not want a child in the next two years, and 36% have an unmet need for effective contraception. Unmet need for family planning is equally high in urban and rural areas. (7) The strong link between low educational attainment and early motherhood suggests that improving educational opportunities for girls is a promising way of reducing high levels of adolescent childbearing in Nicaragua.